All Content

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.

Patients with mental health concerns are vulnerable to harm from medication errors. This investigation report describes factors that contributed to the deaths of two psychiatric inpatients and identifies weaknesses in monitoring, polypharmacy review, and off-label medication use as primary concerns.

This guide discusses the impact of poor communication on care transitions and describes tactics for improvement.

This publication analyzes 72,482 medication incidents reported to the National Health Service and highlights areas for improvement and prevention.

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.