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1 - 5 of 5
Newcastle upon Tyne, UK: Care Quality Commission; December 2018.
The term never events was originally coined to describe rare, devastating, and preventable events. This report provides an analysis of National Health Service (NHS) efforts to optimize use of alerts, guidance, and recommendations to prevent never events. The investigation found that NHS staff feel unsupported by training, challenged by complex processes of care to practice safely, and uncertainty regarding improvement roles at the system level.
London, UK: National Patient Safety Agency; 2009. ISBN: 9781906624088.
This publication analyzes 72,482 medication incidents reported to the National Health Service and highlights areas for improvement and prevention.
St Paul, MN: Minnesota Department of Health.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2020 report summarizes information about 366 adverse events that were reported, representing a slight increase each year since the reports were first published. Pressure ulcers and fall-related injuries were the most common incidents documented. Reports from previous years are available.