U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Never Events :
The list of never events has expanded over time to include adverse events that are unambiguous, serious, and usually preventable...
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Device-related Complications (2)
Diagnostic Errors (1)
Identification Errors (12)
Discontinuities, Gaps, and Hand-Off Problems (2)
Medication Safety (7)
Medical Complications (23)
Nonsurgical Procedural Complications (1)
Surgical Complications (32)
Transfusion Complications (4)
Psychological and Social Complications (4)
Australia and New Zealand (1)
North America (64)
Journal Article (34)
Newspaper/Magazine Article (11)
Press Release/Announcement (2)
Special or Theme Issue (1)
Web Resource (1)
Epidemiology of Errors and Adverse Events (24)
Active Errors (16)
Latent Errors (4)
Near Miss (3)
Approach to Improving Safety
Health Care Providers (33)
Health Care Executives and Administrators (57)
Non-Health Care Professionals (34)
Setting of Care
Psychiatric Facilities (1)
Residential Facilities (2)
Ambulatory Care (3)
Outpatient Surgery (4)
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Surgical never events in the United States.
Mehtsun WT, Ibrahim AM, Diener-West M, Pronovost PJ, Makary MA. Surgery. 2013;153:465-472.
Using the Targeted Solutions Tool for wrong site surgery: is your organization at risk?
Oakbrook Terrace, IL: Joint Commission Center for Transforming Healthcare; February 13, 2012.
Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never events.
Hempel S, Maggard-Gibbons M, Nguyen DK, et al. JAMA Surg. 2015 Jun 10; [Epub ahead of print].
Case 34-2010: a 65-year-old woman with an incorrect operation on the left hand.
Ring DC, Herndon JH, Meyer GS. N Engl J Med. 2010;363:1950-1957.
Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery.
Zahiri HR, Stromberg J, Skupsky H, et al. Surg Innov. 2011;18:55-60.
Adverse Health Events in Minnesota: Eleventh Annual Public Report.
St. Paul, MN: Minnesota Department of Health; February 2015.
Preventing unintended retained foreign objects.
Sentinel Event Alert. October 17, 2013;(51):1-5.
To Err Is Human—But Don't Expect to Get Paid For It.
ASQ Quarterly Quality Report. Milwaukee, WI: American Society of Quality; October 2008.
Retained surgical items: a problem yet to be solved.
Stawicki SP, Moffatt-Bruce SD, Ahmed HM, et al. J Am Coll Surg. 2013;216:15-22.
The $17.1 billion problem: the annual cost of measurable medical errors.
Van Den Bos J, Rustagi K, Gray T, Halford M, Ziemkiewicz E, Shreve J. Health Aff (Millwood). 2011;30:596-603.
Never events: Utah hospitals saw nearly 60 serious errors in 2007.
May H. Salt Lake Tribune. August 18, 2008.
Never Events: Framework 2009/10.
National Patient Safety Agency. London, UK: National Reporting and Learning Service; 2009.
Interventions for reducing wrong-site surgery and invasive procedures.
Algie CM, Mahar RK, Wasiak J, Batty L, Gruen RL, Mahar PD. Cochrane Database Syst Rev. 2015;3:CD009404.
Carpenter D. Hosp Health Netw. November 2007;81:34-38.
More states shred bills for awful medical errors: patients in 23 states will no longer pay for certain mistakes, hospitals say.
Aleccia J. MSNBC News. August 12, 2008.
No pay for "never event" errors becoming standard.
O'Reilly KB. American Medical News. January 7, 2008.
How surgical trainees handle catastrophic errors: a qualitative study.
Balogun JA, Bramall AN, Bernstein M. J Surg Educ. 2015 Jun 11; [Epub ahead of print].
Patient characteristics and the occurrence of never events.
Fry DE, Pine M, Jones BL, Meimban RJ. Arch Surg. 2010;145:148-151.
Serious Reportable Events in Healthcare—2011 Update.
Washington, DC: National Quality Forum; 2011. ISBN: 9780982842188.
Incorrect surgical procedures within and outside of the operating room.
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.
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