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What Is a Never Event?

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Everyone makes mistakes, but there are some accidents that should never happen, especially in the healthcare field. Medical errors that should never occur are referred to as “never events,” and sound like the stuff of nightmares.

Unfortunately, never events don’t happen as rarely as their name suggests. Too often, patients wake up with the wrong leg amputated, or with a cotton ball or medical tool stitched into their body.

If you’re reading this, you or someone you love may even have experienced a never event as severe as the examples above. If this is the case, our team at Bertram & Graf, L.L.C. is here for you.

How Many Never Events Are There?

In 2001, Ken Kizer, MD coined the term “never event,” to refer to “particularly shocking medical errors.” Now, the term indicates adverse events that are unambiguous, serious, and (usually) preventable. As of September 2019, the list of never events includes 29 “serious reportable events” separated into 7 categories. Remember: all never events constitute medical malpractice.

Surgical or Procedural Events

Five (5) never events are categorized as surgical or procedural. These never events include:

  1. Wrong-site surgery (or invasive procedure)
  2. Wrong-patient surgery (or invasive procedure)
  3. Wrong surgery (or invasive procedure) performed on the right patient
  4. Retained foreign object or surgical instrument
  5. Certain fatal anesthesia errors

Product or Device Events

The 3 never events categorized as product or device events are:

  1. Patient death or catastrophic injury from contaminated drugs, devices, or biologics
  2. Death or injury from a device used for unintended functions
  3. Death or injury associated with intravascular air embolism

Patient Protection Events

When a medical professional fails to protect their patient, the 3 following never events occur:

  1. Discharge or release of a patient or resident who cannot make decisions
  2. Patient disappearance
  3. Patient suicide or self-harm

Care Management Events

This is the largest category of never events and consists of 9 possible mistakes:

  1. Medication errors that lead to patient death or serious injury
  2. Unsafe administration of blood products
  3. Maternal death or catastrophic injury during labor or delivery in a low-risk pregnancy
  4. Infant death or serious injury in a low-risk pregnancy, labor, and/or delivery
  5. Artificial insemination with the wrong sperm or egg
  6. Falls that lead to serious injury or death in a health care setting
  7. Stage III or IV pressure ulcers acquired in a health care facility
  8. The irretrievable loss of an irreplaceable biological specimen
  9. Failure to communicate or follow up with test results that results in catastrophic injury or death

Environmental Events

Four (4) events appear in the environmental events category:

  1. Electric shock(s) that cause death or disability to patients or staff
  2. Contaminated or improperly filled gas lines (such as a tainted oxygen tank)
  3. Serious burns that lead to death or catastrophic injury
  4. Adverse effects from restraints or bedrails in a health care facility

Radiologic Events

If a metal object is introduced into an MRI machine, patients can be seriously injured or killed. This is the only never event in this category.

Criminal Events

Because they are intentional, criminal events are perhaps the most horrendous instances of never events. Classified situations include:

  • Impersonating a medical professional
  • Patient abduction or kidnapping
  • Sexual assault or abuse
  • Physical assault or battery

Holding the Healthcare Field to Hire Standards

As you can see, never events can be devastating for patients and their families. In fact, 71% of these events lead to death, and countless others lead to catastrophic injury or lifelong disability.

If you or someone you love has been affected by a never event on the list above, or even experienced a situation that sounds similar, you owe it to yourself to contact us at (888) 398-2277 and schedule a free consultation.