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What Is a Medical Error?

A Master List of Never Events from the National Quality Forum

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Updated September 06, 2013

Please note: This list of never events was updated in 2011 and is no longer being used to describe these adverse medical events. Link here to find the most recent information about the National Quality Forum's Serious Reportable Events (the new name for never events).

This list remains online to provide historical perspective.

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

Reminder: This list of never events was updated in 2011 and is no longer being used to describe these adverse medical events. Link here to find the most recent information about the National Quality Forum's Serious Reportable Events (the new name for never events).

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
  • 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

Reminder: This list of never events was updated in 2011 and is no longer being used to describe these adverse medical events. Link here to find the most recent information about the National Quality Forum's Serious Reportable Events (the new name for never events).

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