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.

UK Regulators measure never events to assess hospital safety culture and dictate reimbursement. The authors suggest that regulators focus on reducing the national never event rate through shared learning and an integrated system-wide approach, rather than concentrating on underperforming, outlier hospitals where factors such as safety culture maybe contributing to increased rates of never events.