Never Events: When Doctors Make Serious Preventable Errors

Healthcare researchers have a term for medical errors that are totally unacceptable: never events. In the world of surgery, never events are some of the most devastating, and unconscionable, mistakes that a physician can make. We’re talking about more than mere slip-ups here. Never events are catastrophic, and almost always preventable, sources of extreme injury.

What Is A Never Event In Medical Care?

Never events aren’t restricted to surgical settings, although some of the most notable never events occur during invasive procedures:

• Wrong-site or wrong-procedure surgeries
• Performing surgery on the wrong patient
• Foreign objects left inside a patient

Never events often come down to a lack of adequate communication or careless record-keeping.

In one case of wrong-patient surgery, physicians at Mount Sinai School of Medicine in New York began performing an invasive procedure on their 67-year-old patient, Joan Morris. After about an hour, it became clear to the surgeons that Morris didn’t need the procedure at all. The surgery had been scheduled for Jane Morrison, not Joan Morris. The procedure was quickly stopped and Morris was returned to her room in “stable condition,” according to the 2002 case report, which has now become a textbook example for never events in the medical literature. In attempting to determine what, exactly, led the surgeons to perform their procedure on the wrong patient, researchers identified 17 “distinct” errors, not least of which was a “systematically faulty exchange of information among caregivers.”

28 Never Events

There’s no complete list of never events, but the National Quality Forum, a non-profit that coined the term, outlined 28 different medical errors that fit the bill in 2002:

1. Artificial insemination with the wrong donor sperm or donor egg
2. Unintended retention of a foreign body in a patient after surgery or other procedure
3. Patient death or serious disability associated with patient elopement (disappearance)
4. Patient death or serious disability associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of administration)
5. Patient death or serious disability associated with a hemolytic reaction due to the administration of incompatible blood or blood products
6. Patient death or serious disability associated with an electric shock or elective cardioversion while being cared for in a healthcare facility
7. Patient death or serious disability associated with a fall while being cared for in a healthcare facility
8. Surgery performed on the wrong body part
9. Surgery performed on the wrong patient
10. Wrong surgical procedure performed on a patient
11. Intraoperative or immediately post-operative death in an ASA Class I patient (a normal, healthy patient, as defined by the American Society of Anesthesiologists)
12. Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility
13. 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
14. Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility
15. Infant discharged to the wrong person
16. Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a healthcare facility
17. Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a health care facility
18. Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility
19. Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia (jaundice) in an infant
20. Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility
21. Patient death or serious disability due to spinal manipulative therapy
22. Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances
23. Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility
24. Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility
25. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider
26. Abduction of a patient of any age
27. Sexual assault on a patient within or on the grounds of the healthcare facility
28. Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of the healthcare facility

As you can see, these errors run the gamut, from mistakes made during surgery to inadequate watchfulness over vulnerable patients. No matter their differences, every never event suggests one inescapable fact: that a healthcare facility has a major problem. In order to curb the prevalence of never events, some states have even passed laws, requiring hospitals to report them immediately to health regulators. Today, Minnesota, New Jersey and Illinois have established programs making the reporting of never events mandatory. As an alternative to mandatory reporting laws, some states, including New York, have deemed certain never events “unreimbursable.” In essence, these states cut off Medicaid funding to doctors when they commit serious medical errors.

Defining The Unthinkable

To define a never event in general, we have to look at the effects and causes of a given medical error, rather than the specific situations involved.

Never events are unambiguous. There’s no uncertainty about what happened or why. A serious error was made and a patient was severely hurt. Never events should be “clearly identifiable,” according to the Centers for Medicare and Medicaid Services, so we can easily track their occurrence and direct critical interventions to healthcare systems in which never events are prevalent.

Never events are (usually) preventable. Providing outstanding healthcare is difficult. We all understand that, just as we understand that, in difficult medical situations, mistakes can be made.

Sometimes, even errors that turn out to harm patients aren’t enough to raise questions of civil liability or medical malpractice. What matters in a case of medical negligence is that a doctor deviated from the standard of care, the accepted standards of medical care that other doctors would have followed in a similar situation. One way to think about never events is that a doctor has deviated so far from the accepted path that their actions have entered an entirely different, and intolerable, realm of medical mistakes.

As the name implies, never events should never happen, in large part because careful doctors, nurses and technicians have the ability to prevent them in all but the rarest cases.

Never events lead to serious consequences for patients. To be classified as a never event, a medical error must cause either death, disability or dismemberment, the loss of a body part. Patients don’t “recover” from never events; they are changed forever in adverse ways.

How Common Are Never Events?

We don’t really know. For obvious reasons, most doctors are unwilling to report them, both to preserve their own reputations and to keep their insurance costs down (since a never event would almost always serve as the basis of a viable medical malpractice lawsuit). To make matters worse, few states require that never events are reported in the first place. Small studies suggest that up to 4,000 surgical never events occur every year, but again, this is likely an incomplete sample of the problem’s actual extent.