In medicine, a “never event,” also called a sentinel event, is an incident that should never occur in a patient care setting. Established by the National Quality Forum and the Joint Commission, the list of never events includes occurrences that cause the patient severe temporary harm, permanent harm, death or the need for life-sustaining medical intervention.
Review the facts and statistics about common types of never events and learn more about measures designed to keep patients safe.
Accidental foreign body retention
Joint Commission data showed that more than 14% of reported never events in 2017 involved an object left in the patient’s body after surgery. Whether the object is a surgical sponge, instrument, gauze pad or another item, the patient can experience serious complications including infection, serious internal injuries and organ damage. Seek medical attention right away if you or loved one develops a fever, blood in the vomit, mucus, or stool, unexplained weight loss, trouble breathing or severe pain at the surgical site after a procedure.
Fall in a health care setting
Falls represented just over 14% of never events reported to the Joint Commission in 2017. Improper supervision can lead to falls after a surgical procedure as well as in the long-term care setting for pediatric patients or older adults. Up to half of falls result in serious physical injury, including broken bones. Health care facilities can prevent most patient falls with the proper safety measures in place.
Wrong procedure, patient or site
Nearly 12% of never events in 2017 occurred when a surgeon performed the wrong procedure, operated on the wrong surgical site or performed surgery on the wrong patient. Any of these actions can have dire health consequences, which vary significantly depending on the circumstances of the case.
Although never events are very rare, they are frequently fatal. In fact, 71% of never events between 1995 and 2015 resulted in patient death according to Joint Commission data. Patients and their families have legal recourse when injury or wrongful death occurs because of a never event in the health care setting.