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Karen Boe Gatlin
Karen Boe Gatlin
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Never Events

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“Never events” are identifiable, serious, preventable errors in medical care and are evidence of problems in a health care facility. The exact number of “never events” is unknown, but they result in deaths and additional health care costs. It is estimated approximately 98,000 deaths a year are caused by medical errors. According to the Department of Health and Human Services, “never events” add significantly to Medicare hospital payments, ranging from an average of an additional $700 per case to treat decubitus ulcers to $9,000 per case to treat postoperative sepsis.” Further “medical errors may account for 2.4 million extra hospital days, $9.3 billion in excess charges (for all payers), and 32,600 deaths.” Never Events include:

Surgical Events


Surgery performed on the wrong body part

Surgery performed on the wrong patient

Wrong surgical procedure on a patient

Retention of a foreign object in a patient after surgery or other procedure

Intraoperative or immediately post-operative death in a normal health patient (defined as a Class 1 patient for purposes of the American Society of Anesthesiologists patient safety initiative)

Product or Device Events


Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility

Patient death or serious disability associated with the use or function of a device in patient care in which the device is used or functions other than as intended

Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility

Patient Protection Events


Infant discharged to the wrong person

Patient death or serious disability associated with patient elopement (disappearance) for more than four hours

Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a healthcare facility

Care Management Events


Patient death or serious disability associated with a medication error (e.g., error involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration)

Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO-incompatible blood or blood products

Maternal death or serious disability associated with labor or delivery on a low-risk pregnancy while being cared for in a healthcare facility

Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility

Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates

Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility

Patient death or serious disability due to spinal manipulative therapy

Environmental Events


Patient death or serious disability associated with an electric shock while being cared for in a healthcare facility

Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances

Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility

Patient death associated with a fall while being cared for in a healthcare facility

Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility

Criminal Events


Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider

Abduction of a patient of any age

Sexual assault on a patient within or on the grounds of a healthcare facility

Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare facility

See: www.cms.hhs.gov/apps/media/press/release.asp?Counter=1863