The National Quality Forum defined 28 health care "never events"—patient safety events that pose serious harm to patients, but should be considered entirely preventable. Specific categories of never events include surgical events (eg, wrong site surgery), device events (eg, air embolism), care management events (eg, death or disability due to medication errors), patient protection events (eg, patient suicide), environmental events, and criminal events. Since the development and dissemination of this list, many states have mandated that health care facilities report all instances of these events. When such an event occurs, many institutions mandate performance of a root cause analysis.