Never events are “reasonably preventable” events or occurrences that should never happen in a hospital or healthcare facility. The National Quality Forum (NQF) defines never events as “serious reportable events” and include surgical events, such as performing the wrong procedure; product or device events, such as contaminated drugs or devices; and criminal events, such as sexual assault on a patient.
The 28 never events, as defined by the NQF are:
- artificial insemination with the wrong donor sperm or donor egg
- unintended retention of a foreign object in a patient after surgery
- patient death or serious disability associated with patient disappearance
- patient death or serious disability associated with medication error
- patient death or serious disability associated with electric shock or elective cardioversion
- patient death or serious disability associated with a hemolytic reaction due to administration of blood products
- patient death or serious disability associated with a fall
- surgery performed on the wrong body part
- surgery performed on the wrong patient
- wrong surgical procedure performed on a patient
- intraoperative of immediately post-operative death in an ASA Class I patient
- patient death or serious disability associated with the use of contaminated drugs, devices or biologics provided by the healthcare facility
- patient death or serious disability associated with the use or function of a device in patient care, in which the device is used or functions other than as intended
- patient death or serious disability associated with intravascular air embolism
- infant discharged to the wrong person
- patient suicide or attempted suicide resulting in serious disability
- maternal death or serious disability associated with labor or delivery in a low-risk pregnancy
- patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is cared for in a health facility
- death or serious disability associated with failure to identify and treat hyperbilirubinemia in neonates
- stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility
- patient death or serious disability due to spinal manipulative therapy
- any incident in which a line designated for oxygen or other has to be delivered to a patient contains the wrong gas or is contaminated by toxic substances
- patient death or serious disability associated with a burn
- patient death or serious disability associated with the use of restraints or bedrails
- any instance or care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider
- abduction of a patient of any age
- sexual assault on a patient
- death or significant injury of a patient or staff member resulting from a physical assault
Beginning on October 1, 2008, Medicare will deny payment on such never events that occur in hospitals or healthcare facilities. Hospitals or facilities cannot only be denied payment, but are prohibited from billing the patient and must absorb any and all costs associated with remedying the damage they caused. Although physicians are not yet affected by this new policy, it is expected that the benefits will result from hospitals working harder to prevent these errors and making greater efforts to protect their patients. Medicare is currently seeking a uniform payment policy which will apply to physicians as well.