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PSNet: Patient Safety Network
Journal Article

"Never events" and the quest to reduce preventable harm.

Austin M, Pronovost PJ. Joint Commission journal on quality and patient safety. 2015;41:279-88.

The introduction of the term never events in 2001 was an important catalyst for the patient safety movement. Coined by Dr. Ken Kizer, former CEO of the National Quality Forum (NQF), the term was originally intended to refer to adverse events that were both clinically devastating and largely preventable—such as wrong-site surgery. Establishment of the NQF never events list helped set targets for the safety field and provided an impetus for hospitals to prioritize patient safety efforts. This commentary discusses how the concept of never events has changed over time, noting that although the term originated with the NQF, there are now several different organizations that use the term to refer to different types of events (for example, The Joint Commission's sentinel event list and the Center for Medicare and Medicaid Services no pay for errors list). Data on never events is also used in different ways, with many states mandating reporting of these incidents, but policies around public reporting of never events at the individual hospital vary widely. In light of this evolution, the authors provide recommendations for how data and preventive practices on never events should be used in the future. These include establishing standard definitions and measurement techniques for never events, increased transparency in reporting of errors, and collaborative approaches to developing error prevention methods. A case of a wrong-site surgery is discussed in a recent AHRQ WebM&M commentary.