In 2006 the National Quality Forum (NQF) listed 28 situations which should "never" occur in a healthcare facility. While some of the conditions are definitely preventable, others may not be under the control of a healthcare facility.

Never Events: 28

Outcome: death, serious disability, significant injury, criminal act


Surgical events:

(1) surgery done on the wrong body part

(2) surgery done on the wrong patient

(3) patient undergoing the wrong surgical procedure

(4) unintended retention of a foreign body

(5) intraoperative or immediate postoperative death of a patient classified as ASA Class I

(6) artificial insemination with the wrong donor egg or wrong sperm


Products or device events:

(7) use of contaminated drugs, devices or biologics

(8) use of a device for a function other than intended

(9) intravascular air embolism


Patient protection events:

(10) infant discharged to the wrong person

(11) patient elopement (disappearance)

(12) patient suicide or attempted suicide


Care management events:

(13) medication error

(14) administration of ABO or HLA incompatible blood or blood product

(15) maternal death following labor or delivery of a low-risk pregnancy

(16) hypoglycemia resulting in death or serious disability associated with care delivered

(17) kernicterus (severe hyperbilirubinemia in a neonate)

(18) Stage 3 or 4 pressure ulcer acquired after admission

(19) associated with spinal manipulative therapy


Environmental events

(20) electrical shock

(21) administration of wrong gas or contaminated gas

(22) burn

(23) fall

(24) restraint or bedrail associated


Criminal events:

(25) healthcare provider impersonator

(26) patient abduction

(27) sexual assault

(28) physical assault

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