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What Is a Never Event?

Surgical team performing surgery

In plain English, a never event is a medical nightmare. As defined by the National Quality Forum (NQF) and the Centers for Medicare & Medicaid Services (CMS), never events, or serious reportable events (SREs), are:

errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a healthcare facility.”

Never events can be surgical, environmental, radiologic, or criminal; or be related to products or devices, patient protection, or care management. The most well-known never events are surgical, such as operating on the wrong body part or leaving a foreign object (i.e. a surgical sponge) inside the body. Still, the complete list of never events includes 29 SREs in all 7 categories listed above.

Below, you can find some examples of each:

Surgical Events

Mistakes during surgery are serious and typically involve the wrong patient, body part, or procedure. Surgical never events include:

  • Surgery on the wrong body part
  • Surgery on the wrong patient
  • Wrong surgical procedure on a patient
  • Retention of a foreign object post-procedure
  • The death of a healthy patient

Product or Device Events

A medical provider should never use contaminated drugs or devices on a patient. They also have a responsibility to use medical devices for their intended use. Any time the following actions cause death or serious injury to a patient, they are considered never events:

  • The use of contaminated drugs, devices, or biologics
  • The use of a medical device for functions other than those intended
  • Intravascular air embolism in a health care setting

Patient Protection Events

These events are especially common among the elderly and the mentally ill. Patient protection events consist of:

  • The discharge or release of a patient who is unable to make decisions (except to an authorized person)
  • Death or disability associated with patient disappearance
  • Patient suicide or self-harm while being cared for in a health care facility

Care Management Events

In medical settings, providers are responsible for giving patients the correct medications and keeping them safe from additional harm. Similarly, doctors have a duty of care towards those they treat in every situation. Care management events are caused by:

  • Medication errors that lead to serious injury or death
  • Unsafe administration of blood products
  • Pregnancy-related death or severe maternal morbidity in a low-risk pregnancy
  • Birth injuries or infant death in a low-risk pregnancy
  • Artificial insemination with the wrong sperm or egg
  • Serious falls in health care facilities (i.e. hospitals or nursing homes)
  • Stage 3 or 4 pressure ulcers (bed sores) in health care facilities
  • The irretrievable loss of an irreplaceable biological specimen
  • Failure to follow up or communicate test results (lab, pathology, or radiology)

Environmental Events

Hospitals, nursing homes, and other health care facilities must be safe for patients. When the tools or environment of a facility cause death or serious injury to a patient, the instance is a never event. Environmental events happen when:

  • A patient or staff is killed or seriously injured by an electric shock
  • Oxygen tanks are empty or contaminated, or patients are given the wrong gas
  • Patients or staff are seriously burned
  • Patients are seriously injured or killed by the use of restraints or bedrails

Radiological Event(s)

The only defined radiological event involves the death or injury of a patient or staff associated with metallic objects in the MRI area.

Criminal Events

If you’ve ever watched a true-crime documentary or heard of Ted Bundy, you know that anyone can be a criminal. Unfortunately, the same principle is true in a health care setting. Criminal events include:

  • An individual impersonating a physician, nurse, pharmacist, or other licensed health care provider.
  • Abduction of a patient or resident
  • Sexual abuse or assault of a patient in a health care facility
  • Physical assault on the grounds of a health care facility

Do Any of These Situations Sound Familiar?

If so, you need to contact an attorney immediately. While never events are relatively rare, they are devastating to those affected. Holding providers accountable can assist with your recovery in several ways, and reporting SREs is crucial to protecting those around you.

As their name suggests, never events should never happen. If you’ve experienced a serious reportable event, the Law Office of Charles R. Gueli can help you remedy the situation with a medical malpractice lawsuit.

Call us 24/7 at (516) 628-6402 for a free, confidential consultation.

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