When a patient is about to undergo treatment or surgery for a particular medical condition, certain adverse effects may be inevitable. In other cases, adverse effects may be a result of a medical mistake. While certain errors are understandable, some are so shocking and outrageous that they should never have happened. These events are commonly known as “never events.” The term was first coined in 2001 by Ken Kizer, MD, a former CEO of the National Quality Forum (NQF).
The NQF identifies 29 events that are considered to be never events. Some examples include:
- Surgeons operating on the wrong person;
- Surgeons operating on the wrong body part;
- Surgeons performing the wrong procedure altogether;
- Leaving a foreign object in the patient’s body;
- Using dirty or unsterilized medical instruments in surgery;
- Infusing the wrong blood type into a patient;
- Death or injury resulting from the introduction of a metallic object into an MRI area;
- Oxygen lines containing no gas or the wrong gas; or
- Permitting medical personnel to treat a patient while the personnel is intoxicated or under the influence of drugs.
In 2007, the Leapfrog Group began tracking data on never events. In 2015, the group released a report stating that one in five hospitals in the United States do not meet the group’s standards for accurately reporting when never events take place.