The National Quality Forum calls these 28 medical errors "never events," meaning, of course, that they should never happen.
Most of these mistakes are likely to happen while a patient is being cared for in a healthcare facility. Others can happen anywhere, including in a patient's home.
Surgical Events
* Surgery performed on the wrong body part
* Surgery performed on the wrong patient
* Wrong surgical procedure on a patient
* Retention of a foreign object in a patient after surgery or other procedure
* Intraoperative or immediately post-operative death in a normal healthy patient
Product or Device Events * Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility
* 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
* Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility
Patient Protection Events * Infant discharged to the wrong person
* Patient death or serious disability associated with patient disappearance for more than four hours
* Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a healthcare facility
Care Management Events * Patient death or serious disability associated with a medication error
* Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO-incompatible blood or blood products (transfusion of the wrong blood type)
* Maternal death or serious disability associated with labor or delivery on a low-risk pregnancy while being cared for in a healthcare facility
* Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility
* Death or serious disability (kernicterus) associated with failure to identify and treat jaundice in newborns
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Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility
* Patient death or serious disability due to spinal manipulative therapy
Environmental Events * Patient death or serious disability associated with an electric shock while being cared for in a healthcare facility
* 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
* Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility
* Patient death associated with a fall while being cared for in a healthcare facility
* Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility
Criminal Events * Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider
* Abduction of a patient of any age
* Sexual assault on a patient within or on the grounds of a healthcare facility
* 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 a healthcare facility
Many patients are surprised to learn that hospital-acquired infections such as MRSA or C.Diff are not included on this list.
Patient safety is now being addressed by a number of groups across the country. The National Patient Safety Foundation sponsors a week in March each year to call attention to patient safety issues.
What Is a Medical Error -- A Master List of Never Events from the National Quality Forum
