A “never event” is a medical error that is “unacceptable and eminently preventable” and therefore should never occur. The term was first used by the National Quality Forum (NQF) in 2001 and resulted in a list of “never events” that are clearly identifiable and measurable and that result in death or significant disability. The first never events list was established in 2002 and defined 27 such adverse events. The never events list has been revised since then and is grouped into categories: surgical, product or device, patient protection, care management, environmental, radiologic, and criminal.
The full ‘never events’ list for 2012/13 is:
- wrong site surgery
- wrong implant/prosthesis
- retained foreign object post-operation
- wrongly prepared high-risk injectable medication
- maladministration of potassium-containing solutions
- wrong route administration of chemotherapy
- wrong route administration of oral/enteral treatment
- intravenous administration of epidural medication
- maladministration of Insulin
- overdose of midazolam during conscious sedation
- opioid overdose of an opioid-naïve patient
- inappropriate administration of daily oral methotrexate
- suicide using non-collapsible rails
- escape of a transferred prisoner
- falls from unrestricted windows
- entrapment in bedrails
- transfusion of ABO-incompatible blood components
- transplantation of ABO-incompatible organs as a result of error
- misplaced naso- or oro-gastric tubes
- wrong gas administered
- failure to monitor and respond to oxygen saturation
- air embolism
- misidentification of patients
- severe scalding of patients
- maternal death due to post partum haemorrhage after elective Caesarean section.
How Prevalent Are “Never Events” In Medical Malpractice Claims?
A study published on December 18, 2012 in the medical journal Surgery looked at the number and magnitude of paid malpractice claims for surgical never events, as well as associated patient and provider characteristics, by examining the payment amounts, patient outcomes, and provider characteristics for malpractice settlements and medical malpractice judgments involving surgical never events reported to the National Practitioner Data Bank. The surgical never events studied included retained foreign bodies, wrong-site, wrong-patient, and wrong-procedure surgery claims.
The researchers were able to identify 9,744 paid medical malpractice settlements and medical malpractice judgments for surgical never events that occurred between 1990 and 2010. The total medical malpractice payments for surgical never events during that period was $1.3 billion. Death was the result for 6.6% of the patients. Permanent injury was the result in 32.9% of the patients and temporary injury occurred in 59.2% of the patients. The researchers estimated that 4,082 surgical never events claims occur every year in the United States. They also found that 12.4% of the medical malpractice physicians named in medical malpractice claims involving surgical never events were also named as medical malpractice defendants in at least one subsequent surgical never event medical malpractice claim reported to the National Practitioner Data Bank.
“Never events” are extraordinarily expensive in terms of unnecessary and wasted heath care costs in the United States. Beyond the substantial amount of health care resources re-directed away from necessary patient care and services to address adverse outcomes that, by definition, were “unacceptable and eminently preventable” and should never have occurred, the tragic consequences for patients and their families who are the victims of never events are unacceptable and should never have occurred.
If you, a family member, a loved one, or a friend may have suffered harms as the result of a never event in the United States, you should promptly contact a local medical malpractice attorney to investigate your medical malpractice claim for you and file a medical malpractice lawsuit on your behalf against the responsible health care providers, if appropriate.
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