Dr. Ken Kizer introduced the term “never event” in 2001. Never events are medical errors that should never happen and can cause death or serious injury. These events are recognizable and preventable and show safety and integrity issues in the health care setting where the event occurred.
Over a 12-year period, the Joint Commission found that over 70% of never events caused fatalities. Here are four types of never events.
1. Surgical
Without precaution, simple surgeries can turn into lifetime problems. Surgical never events may include:
- Surgery on the wrong body part
- Surgery on the wrong patient
- Incorrect surgery performed
- Foreign bodies, such as surgical tools, left inside the patient
2. Patient protection
Patient protection never events may include:
- The hospital releases a patient who cannot make their own decisions
- A patient who disappears becomes injured or dies
- A patient commits suicide, attempted suicide or self-harm
3. Care management
Care management events may consist of medical errors such as incorrect drug doses or using the wrong drug and giving a specific type of care to the wrong patient. Other care management never events may include health care workers not following up on lab results promptly.
4. Environmental
Environmental events may comprise:
- Electric shock during patient care
- Oxygen or other gas lines that contain no gas, the wrong gas or a toxic substance
- A patient receiving a burn that results in injury or death
- Death or injury when using bed restraints on a patient
Knowing about these never events may keep you more aware of how the medical community should care for you and your loved ones.
