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Identifying a list of healthcare 'never events' to effect system change: a systematic review and narrative synthesis.
July 12, 2023
Bowman CL, De Gorter R, Zaslow J, et al. BMJ Open Qual. 2023;12(2):e002264.
Never events are catastrophic adverse events resulting in patient death or significant disability that are largely preventable. This narrative synthesis describes which events organizations most frequently identify as never events, and which are most commonly described as entirely preventable. 125 unique never events were identified, nearly 20% of which were classified as entirely preventable. The most frequent never events were wrong site or wrong patient surgery, wrong surgical procedure, and unintentionally retained objects.
