The 29 Never Events – The Worst Medical Mistakes

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As New York’s top medical malpractice law firm, we’ve seen some terrible, terrible cases of medical malpractice and medical negligence. 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.

Luckily, these tragedies are exceedingly rare. A 2006 study estimated that a typical hospital might experience a case of wrong-site surgery once every 5 to 10 years. 

However, when never events occur, they are devastating to patients – 71% of events reported to the Joint Commission over the past 12 years were fatal–and may indicate a fundamental safety problem within an organization. Although individual events are uncommon, on a population basis, many patients still experience these serious errors. A 2013 study estimated that more than 4000 surgical never events occur yearly in the United States.

What is a Never Event?

A never event is just what it sounds like: an event in a medical setting that should never, ever happen under any circumstance. Typically, all never events are grounds for a lawsuit, whether it be a medical malpractice or wrongful death lawsuit. 

The term “never event” was first introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF), in reference to particularly shocking medical errors—such as wrong-site surgery—that should never occur. Over time, the term’s use has expanded to signify adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable.

Kizer developed the first never event list in 2002. Since then, the list has been revised several times. It now includes 29 “serious reportable events” that are organized into 7 categories:

  1. Surgical or procedural events
  2. Product or device events
  3. Patient protection events
  4. Care management events
  5. Environmental events
  6. Radiologic events
  7. Criminal events

The 29 Never Events

If you or a loved one were affected by any of the 29 never events below, contact Merson Law PLLC to have your case evaluated. You may be able to claim financial compensation for medical malpractice.

  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, dose, patient, time, rate, preparation or route of administration)
  5. Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO/HLA-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 postoperative death in an ASA Class I patient
  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 healthcare 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 in neonates
  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

(List courtesy of Wikipedia)

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