In 2001, Ken Kizer, M.D., introduced the term “never event.” The phrase describes medical errors that should never happen, which may include death or serious injury. The events are recognizable and severe for patients and show a problem with the safety and integrity of a health care institution.
According to The Joint Commission, 71% of never events between 1995 and 2015 caused fatalities. The Joint Commission reported in 2017 that over 800 never events occurred. There are seven categories of never events:
Surgical events may include:
- Procedure on the wrong body part
- Procedure on the wrong patient
- Wrong surgery performed
- Foreign bodies left inside the patient after an operation
2. Product or device
A product or device event occurs when a person misuses the item. A never event may happen with the use of contaminated drugs or devices, or when an intravascular air embolism takes place.
3. Patient protection
Patient protection events may include:
- Discharge or release of a patient who cannot make decisions
- Death or serious disability of a patient who disappears
- Suicide, attempted suicide or self-harm
4. Care management
Care management events may comprise of medical errors such as incorrect drugs or doses, wrong patient or incorrect preparation. These near events may also occur when health care staff does not follow up with a patient for laboratory, pathology or radiology test results.
Environmental events may consist of:
- Electric shock during patient care
- Oxygen or other gas lines that contain no gas, the wrong gas or a toxic substance
- Death or injury associated with a burn in the patient care process
- Death or injury of a patient when using restraints or bedrails
A radiologic event is an incident related to the MRI. Accidents, such as missing a patient’s metal implant, may occur when a metal object comes within the magnet’s range and may cause injury or death.
A criminal near event may include any care of an individual by a person impersonating health care staff. An abduction of a patient, sexual abuse or assault and death on the grounds of a health care facility may also be a near event.