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 2021 report summarizes information about 508 adverse events that were reported, representing a significant increase in the year covered. Earlier reports document a fairly consistent count of adverse events. The rise reflected here is likely due to demands on staffing and care processes associated with COVID-19. Pressure ulcers and fall-related injuries were the most common incidents documented. Reports from previous years are available.

Wrong site/wrong patent surgery is a persistent healthcare never event. This report examines National Health Service (NHS) reporting data to identify how ambulatory patient identification errors contribute to wrong patient care. The authors recommend that the NHS use human factors methods to design control processes to target and manage the risks in the outpatient environment such as lack of technology integration, shared waiting area space, and reliance on verbal communication at clinic.

Cataract surgery, one of the most common procedures in the United States, is vulnerable to wrong-site errors. This consensus report reviews the types of errors associated with cataract surgery and discusses evidence-based practices to reduce risks.

This report shares the 2010-2011 results of Western Australia's sentinel event reporting program. Patient suicide is the highest recorded sentinel event. The data is placed in the context of the overall data collected since the program's launch in 2003.

This Web site includes information and resources for National Time Out Day, an initiative to raise awareness on the importance of surgical team time outs. The annual observation is in June.

According to an AHRQ-supported study, wrong-site surgery occurred at a rate of approximately 1 per 113,000 operations between 1985 and 2004. In July 2004, The Joint Commission enacted a Universal Protocol that was developed through expert consensus on principles and steps for preventing wrong-site, wrong-procedure, and wrong-person surgery. The Universal Protocol applies to all accredited hospitals, ambulatory care, and office-based surgery facilities. The protocol requires performing a time out prior to beginning surgery, a practice that has been shown to improve teamwork and decrease the overall risk of wrong-site surgery. This Web site includes a number of resources and facts related to the Universal Protocol. Wrong-site, wrong-procedure, and wrong-patient errors are all now considered never events by the National Quality Forum and sentinel events by The Joint Commission. The Centers for Medicare and Medicaid Services have not reimbursed for any costs associated with these surgical errors since 2009.

A brief presentation of "pearls" to allow consumers to take an active role in preventing medical errors.

This coalition supports a network of patient safety professionals to facilitate dialogue, promote initiatives on eliminating wrong-site surgery, and improve medication safety.