U.S. Department of Health and Human Services
Agency for Healthcare Research and Quality: Advancing Excellence in Health Care
Sign up for a Free Account
Toronto, ON: Health Quality Ontario and the Canadian Patient Safety Institute; September 2015. ISBN: 9781460666180.
The never events list was developed to reduce harmful clinical incidents. This report reviews the results of a consensus effort to determine a list of never events for hospital care in Canada, including patient suicide, wrong-site surgery, and use of improperly sterilized instruments.
Opening the Door to Change. NHS Safety Culture and the Need for Transformation.
Newcastle upon Tyne, UK: Care Quality Commission; December 2018.
It is time to define antimicrobial never events.
Liu J, Kaye KS, Mercuro NJ, et al. Infect Control Hosp Epidemiol. 2019;40:206-207.
Assessment of incorrect surgical procedures within and outside the operating room. A follow-up study from US Veterans Health Administration medical centers.
Neily J, Soncrant C, Mills PD, et al. JAMA Network Open. 2018;1:e185147.
Unintentionally retained foreign objects: a descriptive study of 308 sentinel events and contributing factors.
Steelman VM, Shaw C, Shine L, Hardy-Fairbanks AJ. Jt Comm J Qual Patient Saf. 2018 Oct 16; [Epub ahead of print].
Patterns of dementia treatment and frank prescribing errors in older adults with Parkinson disease.
Mantri S, Fullard M, Gray SL, et al. JAMA Neurol. 2019;76:41-49.
Developing agreement on never events in primary care dentistry: an international eDelphi study.
Ensaldo-Carrasco E, Carson-Stevens A, Cresswell K, Bedi R, Sheikh A. Br Dent J. 2018;224:733-740.
Adverse Health Events in Minnesota: 15th Annual Public Report.
St. Paul, MN: Minnesota Department of Health; March 2019.
Defending a "never event."
Shepperd JR. J Healthc Risk Manag. 2017;37:17-22.
Patient safety in dentistry: development of a candidate 'never event' list for primary care.
Black I, Bowie P. Br Dent J. 2017;222:782-788.
Indiana Medical Error Reporting System: Final Report for 2015.
Whitson T, Garten B. Indianapolis, IN: Indiana State Department of Health; 2017.
The hidden costs of reconciling surgical sponge counts.
Steelman VM, Schaapveld AG, Perkhounkova Y, Storm HE, Mathias M. AORN J. 2015;102:498-506.
Getting rid of "never events" in hospitals.
Morgenthaler T, Harper CM. Harv Bus Rev. October 20, 2015.
Use of temporary names for newborns and associated risks.
Adelman J, Aschner J, Schechter C, et al. Pediatrics. 2015;136:327-333.
Surgical never events and contributing human factors.
Thiels CA, Lal TM, Nienow JM, et al. Surgery. 2015;58:515-521.
"Never events" and the quest to reduce preventable harm.
Austin JM, Pronovost PJ. Jt Comm J Qual Patient Saf. 2015;41:279-288.
Incidence of "never events" among weekend admissions versus weekday admissions to US hospitals: national analysis.
Attenello FJ, Wen T, Cen SY, et al. BMJ. 2015;350:h1460.
The July effect: an analysis of never events in the nationwide inpatient sample.
Wen T, Attenello FJ, Wu B, Ng A, Cen SY, Mack WJ. J Hosp Med. 2015;10:432-438.
Interventions for reducing wrong-site surgery and invasive procedures.
Algie CM, Mahar RK, Wasiak J, Batty L, Gruen RL, Mahar PD. Cochrane Database Syst Rev. 2015;3:CD009404.
Maryland Hospital Patient Safety Program Annual Report: Fiscal Year 2017.
Office of Health Care Quality. Baltimore, MD: Maryland Department of Health and Mental Hygiene; 2018.
Surgical never events in the United States.
Mehtsun WT, Ibrahim AM, Diener-West M, Pronovost PJ, Makary MA. Surgery. 2013;153:465-472.
Hospital Incident Reporting Systems Do Not Capture Most Patient Harm.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; January 2012. Report No. OEI-06-09-00091.
Challenges and opportunities to prevent transfusion errors: a Qualitative Evaluation for Safer Transfusion (QUEST).
Heddle NM, Fung M, Hervig T, et al; BEST Collaborative. Transfusion. 2012;52:1687-1695.
Serious Reportable Events in Healthcare—2011 Update.
Washington, DC: National Quality Forum; 2011. ISBN: 9780982842188.
Centers for Medicare & Medicaid Services.
PSNET: Patient Safety Network
PSNet is produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Technical Expert/Advisory Panel. The AHRQ PSNet site was designed and implemented by Silverchair.
Agency for Healthcare Research and Quality
5600 Fishers Lane
Rockville, MD 20857
Telephone: (301) 427-1364