AHRQ Patient Safety Network - Patient Safety Primers

Never Events

Background

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 list has been expanded to signify adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable. The NQF initially defined 27 such events in 2002 and revised and expanded the list in 2006. The list is grouped into six categorical events: surgical, product or device, patient protection, care management, environmental, and criminal.


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AHRQ Patient Safety Network - Patient Safety Primers