A never event is the "kind of mistake ( medical error) that should never happen" in the field of medical treatment. [1] According to the Leapfrog Group never events are defined as " adverse events that are serious, largely preventable, and of concern to both the public and health care providers for the purpose of public accountability." [2]
A 2012 study reported there may be as many as 1,500 instances of one never event, a retained foreign object, per year in the United States. The same study suggests an estimated total of surgical mistakes at just over 4,000 per year in the United States, but these statistics are extrapolations from small samples rather than actual event counts. [1]
A list of events was compiled by the National Quality Forum and updated in 2012. [3] The NQF’s report recommends a national state-based event reporting system to improve the quality of patient care.
As of 2019, 11 states have mandated reporting for never events, and an additional 16 states have mandated reporting for serious adverse events including never events. [4]
The National Patient Safety Agency produced a list of eight core never events in March 2009: [5]
NHS England produced a report on 148 reported never events in the period from April to September 2013 highlighting particular hospitals with more than one such event. [6] In 2021 there were still about 500 never events each year in the English NHS. According to Jeremy Hunt a hospital can get as many as 108 safety related instructions in a year. [7]
NHS Improvement has produced monthly and cumulative annual reports since 2015, when the definition of what constitutes a Never Event in the NHS also changed to require not only actual patient harm but also the potential for significant actual harm. Annual counts have therefore increased, and comparing recent with older data is misleading. The definition continues to undergo more minor change. [8] A provisional report for the 10 month period April 1st 2017 to 31st Jan 2018 acknowledged 393 never events within NHS England, including 172 wrong site surgeries, 97 retained foreign body post procedures, 60 wrong implants/prostheses and 31 medication administration errors. [9]
The Leapfrog Group suggested four actions to be taken following a never event: [10]
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A never event is the "kind of mistake ( medical error) that should never happen" in the field of medical treatment. [1] According to the Leapfrog Group never events are defined as " adverse events that are serious, largely preventable, and of concern to both the public and health care providers for the purpose of public accountability." [2]
A 2012 study reported there may be as many as 1,500 instances of one never event, a retained foreign object, per year in the United States. The same study suggests an estimated total of surgical mistakes at just over 4,000 per year in the United States, but these statistics are extrapolations from small samples rather than actual event counts. [1]
A list of events was compiled by the National Quality Forum and updated in 2012. [3] The NQF’s report recommends a national state-based event reporting system to improve the quality of patient care.
As of 2019, 11 states have mandated reporting for never events, and an additional 16 states have mandated reporting for serious adverse events including never events. [4]
The National Patient Safety Agency produced a list of eight core never events in March 2009: [5]
NHS England produced a report on 148 reported never events in the period from April to September 2013 highlighting particular hospitals with more than one such event. [6] In 2021 there were still about 500 never events each year in the English NHS. According to Jeremy Hunt a hospital can get as many as 108 safety related instructions in a year. [7]
NHS Improvement has produced monthly and cumulative annual reports since 2015, when the definition of what constitutes a Never Event in the NHS also changed to require not only actual patient harm but also the potential for significant actual harm. Annual counts have therefore increased, and comparing recent with older data is misleading. The definition continues to undergo more minor change. [8] A provisional report for the 10 month period April 1st 2017 to 31st Jan 2018 acknowledged 393 never events within NHS England, including 172 wrong site surgeries, 97 retained foreign body post procedures, 60 wrong implants/prostheses and 31 medication administration errors. [9]
The Leapfrog Group suggested four actions to be taken following a never event: [10]
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cite journal}}
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help)