In 2011 the National Quality Forum (NQF) updated its list of serious reportable ("never") events released for 2006. 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: 29 (1 more than 2006)
Outcome: death, serious disability, significant injury, criminal act
Surgical events:
(1) surgery done on the wrong body part or site
(2) surgery done on the wrong patient
(3) patient undergoing the wrong surgical or invasive procedure
(4) unintended retention of a foreign body
(5) intraoperative or immediate postoperative death of a patient classified as ASA Class I
Products or device events:
(6) use of contaminated drugs, devices or biologics
(7) use of a device for a function other than intended
(8) intravascular air embolism
Patient protection events:
(9) person of any age who is unable to make decisions discharged to an unauthorized person
(10) patient elopement (disappearance)
(11) patient suicide or attempted suicide
Care management events:
(12) medication error
(13) unsafe administration of any blood product
(14) of mother following labor or delivery of a low-risk pregnancy
(15) of infant following labor or delivery of a low-risk pregnancy
(16) from fall
(17) Stage 3, Stage 4 or ungradable pressure ulcer acquired after admission
(18) artificial insemination with the wrong donor egg or wrong sperm
(19) irretrievable loss of a biological specimen
(20) failure to followup or communicate clinical information
Environmental events
(21) electrical shock
(22) administration of wrong gas or contaminated gas
(23) burn
(24) restraint or bedrail associated
Radiologic events:
(25) associated with introduction of a metallic object into the MRI area, involving patient or staff
Potential criminal events:
(26) healthcare provider impersonator
(27) patient abduction
(28) sexual assault
(29) physical assault (battery)
Summary of Changes
New items:
(15) infant following labor or delivery of a low-risk pregnancy
(19) irretrievable loss of a biological specimen
(20) failure to followup or communicate clinical information
(25) associated with introduction of a metallic object into the MRI area, involving patient or staff
Items delisted from 2006:
(16) hypoglycemia resulting in death or serious disability associated with care delivered
(17) kernicterus (severe hyperbilirubinemia in a neonate)
(19) associated with spinal manipulative therapy
Reworded:
(9) person of any age who is unable to make decisions discharged to an unauthorized person
(13) unsafe administration of any blood product
