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1. [Available at] Most Never events are very rare

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2. However, when Never events occur, they are devastating to patients–71% of events reported to the Joint Commission over the past 12 years were …

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3. BACKGROUND: According to the National Quality Forum (NQF), “Never events” are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility

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4. The criteria for “Never events” are listed in Appendix 1.

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5. Often called Never events, these include

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6. Serious Reportable Events aka "Never events"

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7. The worst of these, called “Never events” in the medical community, are often shocking, disturbing, and downright deplorable on the part of negligent medical professionals

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8. Sadly, Never events may be far more common than most people believe

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9. A “Never events” in medical care is a medical errors that should never occur

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10. The NQF now identifies 29 separate events, ranging in classification from surgical Never events to criminal Never events.

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11. What Are “Never events?” The national nonprofit organization, National Quality Forum (NQF), first developed a list of “Serious Reportable Events” in 2002

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12. A former CEO at NQF coined the term “Never events,” which came to be used in its place

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13. Even though Never events should never happen, there are occasions when they do

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14. Have mandatory reporting of Never events,3 only a few states report such events publicly

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15. Minnesota has had a mandatory reporting program for Never events in place since 2005 and has averaged roughly 100-150 reported Never events per year

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16. Never events are indeed relatively rare, and Leapfrog recognizes that processes sometimes fail and human

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17. The Never events included on Medicare's list are problems like wrong-site surgeries, transfusion with the wrong blood type, pressure ulcers (bedsores), falls or trauma, and nosocomial infections (hospital-acquired infections) associated with surgeries or catheters

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18. The eight are derived from a master list of 28 Never events, so-named, of course

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19. The Never events policy and framework sets out the NHS’s policy on Never events

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20. Never events is a term that refers to mistakes that should never occur in the medical field

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21. Never events: Directed by Angela Asatrian

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22. The introduction of the term Never events in 2001 was an important catalyst for the patient safety movement

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23. Never events are defined in this course as: a

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24. Beginning on October 1, 2008, hospitals will no longer receive higher payments for patients with these conditions, termed Never events

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25. That means "Never events" are occurring more than 10 times a day, or at least 4,000 times a year

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26. Mistakes such as these are called "Never events" as there is a universal professional agreement that these types of incidents should never take place during surgery.

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27. Never events - clinical and surgical patient events that should never occur

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28. Infections, pressure ulcers, patient falls and patient elopement and wandering are examples of highly visible Never events and investing in the right tools, solutions and procedures is key to preventing these Never events.

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29. Never events policies are also recorded in Canada and the US, where there have been studies into their impact on cost and safety

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30. Though Never events continue to happen, we can never be complacent.

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31. New Additions to the “Never events” List

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32. You are probably familiar with the CMS “Never events” initiative

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33. More than 4,000 surgical Never events occur each year in the U.S., according to a 2013 study

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34. Define Never events and related safety initiatives of the National Quality Forum and other organizations such as the Center for Medicare and Medicaid Services, the Joint Commission, the American Nurses Association, and the Leapfrog Group

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35. Identify the categories of National Quality Forum Never events and examples of specific Never events

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36. Understanding Never events and their consequences to patients and the organization is the first step in prevention

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37. After Never events are better understood, nurses can work diligently to prevent them by practicing high-reliability principles and helping to develop better systems and processes that protect patients from harm

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38. Never events : Adverse events or errors in medical care that are clearly identifiable, preventable and present serious consequences to patients

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39. Never events are, as their name implies, medical events that should never happen

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40. "Never events" are patient safety incidents that result in serious patient harm or death, and are preventable using organizational checks and balances

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41. An Action Team from the National Patient Safety Consortium has sought consensus on the top priorities for Canadian Never events in health care

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42. The revised Never events policy and framework and updated Never events list was published in January 2018, to become active upon initiation of the update to the 2017–2019 NHS Standard Contract on 1 February 2018

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43. Never events policy and framework – revised January 2018

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44. Never events list 2018 (last updated 23 February 2021 – see

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45. Never events (NE), adverse events (AE), hospital-acquired conditions (HAC), and serious reportable events (SRE) are types of conditions or events which have negative health effects and are monitored, tracked, and reported

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46. Award winning documentary Never events gives an in-depth look into the heartbreaking true stories of those affected by preventable medical errors in hospitals

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47. Preventing Never events and Ensuring Quality Patient Care

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48. Also called “Never events,” these SREs should never occur in the hospital

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49. To Never events and other preventable medical errors

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50. As a result, the term “Never events” is no longer specific to the

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51. Surgical “Never Events” Experienced Medical Malpractice Attorneys in Kansas City

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52. Surgical “never events” should not happen, but they occur every day

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53. Environmental events – These Never events include oxygen lines containing the wrong gas or no gas at all, electrical shock, burn injuries, and the use of restraints that result in serious injury or death

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54. Background: Never events (NEs) are serious clinical incidents that cause potentially avoidable harm and impose a significant financial burden on healthcare systems

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55. The purpose of this study was to identify common Never events

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56. Methods: We analysed the NHS England NE data from 2012 to 2020 to identify common Never events category and themes.

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57. Never events refer to a list of serious medical errors or adverse events (for example, wrong site surgery or hospital-acquired pressure ulcers) that should never happen to a patient

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58. The Centers for Medicare and Medicaid Services (CMS) defines Never events as “seri-ous, preventable, and costly medical errors.”

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59. The ‘Never events’ is a listing of 28 categorized errors that CMS has determined to be clearly preventable

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60. Hospitals and their staff are under increasing pressure to avoid "Never events," those serious outcomes that supposedly ought never to

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61. The documentary Never events exposes the prevalence of preventable medical mistakes, the kind that need never occur and yet still do with alarming frequency

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62. As part of Aetna's commitment to patient safety and quality, Aetna will not pay facility charges for "Never events" (NE) and some "Serious Reportable Events" (SRE) as described below

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63. The definition of Never events in the numerator has changed over time

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64. Preventing 'Never events': Evidence Based Nurse Staffing

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65. Understanding "Never events" is confusing at best

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66. Never events in the creation of individual State policies

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67. It is critical that as a nurse, you use evidence-based protocols to provide safe patient care and minimize or avoid the occurrence of “Never events,” or medical errors that should never occur

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68. We’ve created the Never events Collections below to help you understand best practices to maximize patient safety and

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Dictionary

NEVER EVENTS [never event]

Frequently Asked Questions

What is an example of a NEVER event?

A Never Event is described as a particularly shocking medical error that should never occur in the healthcare environment. Examples of Never Events include patient suicide, infant abduction, or retention of a foreign object in a patient’s body after surgery.

What is never event in healthcare?

"Never event" is an expression in healthcare that refers to events that are never supposed to happen in a hospital -- preventable problems like falls, air embolisms, bedsores, or infections that occur after a patient's admission to the hospital. And never event sounds so reassuring.

What is never event in surgery?

never event. A term of art for an event (for which there is universal professional agreement) that should never happen during surgery. Sponge, gauze or surgical instrument left in the body after surgery; performing the wrong procedure, or on the wrong site or on the wrong patient.

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