Never Events

I was recently given this list at my workplace. No, not a list of things that happen to Peter Pan and his buddies. This is a serious list of serious occurrences. Meanwhile, since they happen, they are really Rarely Events. Also, if you look at each event, you would probably think that you don't need the three rights, since, for instance, you probably shouldn't be charged for having the wrong kidney removed. So I'm glad to know that I have a right to expect to not be abducted at the hospital and that if I am abducted I should get a report and not be charged for my room while I'm with the kidnappers.

Know your rights, if any of these Never Events happen to you:

• You have a right to be informed by the provider that a “never event” has happened to you.
• You have the right to see a report prepared by the hospital detailing what happened and how it occurred.
• You and your health plan should not be charged for costs and deductibles related to the event. Nor should you be charged for any necessary remediation.

Here is a list of the 28 "serious reportable events" as defined by NQF:

1. Surgery on the wrong body part
2. Surgery performed on the wrong patient
3. Wrong surgical procedures performed on a patient
4. Unintended retention of a foreign object in a patient after surgery or other procedure
5. Interoperative or immediately postoperative death in an ASA Class I patient
6. Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility
7. 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 intended
8. Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility
9. Infant discharged to the wrong person
10. Patient death or serious disability associated with patient elopement (disappearance)
    
11. Patient suicide, or attempted suicide, resulting in serious disability while being cared for in healthcare facility
12. Patient death or serious disability associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration)
13. Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO/HLA incompatible blood or blood products
14. Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare facility
15. Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility
16. Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates
    
17. Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility
18. Patient death or serious disability due to spinal manipulative therapy
19. Artificial insemination with the wrong donor sperm or wrong egg
20. Patient death or serious disability associated with an electric shock while being cared for in a healthcare facility
21. 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
22. Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility
23. Patient death or serious disability associated with a fall 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 a 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 a healthcare facility Blue
    

Please tell us what you think of this list.