never event

n. a (serious or life-endangering) medical error. Subjects: English, Medical, Euphemism, Jargon

Editorial Note: So-called because such occurrences should never happen.

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Citations: 2000 National Quality Forum Management Report (Sept.) “Board of Directors Meeting”: We responded to the DHHS RFP for hospital performance standards and both patient safety projects (patient safety best practices and medical error “never events”) on August 4th. 2001 Ed Lovern Modern Healthcare (May 28) “Holding hospitals accountable” vol. 31, no. 22, p. 6: Hospitals should be required to report certain medical errors to publicly accessible, state-run databases to create a level of accountability now lacking in the healthcare system, the National Quality Forum recommended in a report released last week.…The list of what the NQF calls “never events,” or events that should never occur in a hospital, would provide a standard for states to use in refining or developing systems for collecting adverse medical-event information. 2006 Christina Orlovsky NurseZone.com (Jan. 6) “Illinois Passes Never-Events Law ”: In an effort to identify and prevent serious medical errors known as “never events,” Illinois has recently passed a law requiring health care facilities to analyze and publicly report a variety of adverse occurrences. 2006 Keith Darcé Union-Tribune (San Diego, California) (June 25) “Scripps, Sharp sued in Medicare cases”: U.S. taxpayers for years have been footing a huge bill for hospital errors, known as “never events” in health care industry parlance.…“As a necessary step toward encouraging better care and lower overall health care costs, we support further steps such as eliminating payments for never events.”

Posted 30 Jun 06 | Permalink | Tell a Friend

Reader comments:

Considering the legislation being enacted that refers to this list, they do a good job of not making it available online.

by Bob Kamman 18 Dec 06, 1219 GMT

Bob - see following link for the NWF list:

http://www.qualityforu m.org/pdf/news/prSeriousR eportableEvents10-15-06.p df

by Helen Friedman 22 May 08, 0447 GMT

I submitted the following to the CDC on July 9th. ” I’m looking to obtain information regarding the reuse of in-line galvanic oxygen sensors. Sensors placed on the inspiratory limb of ventilators and anesthesia breathing curcuits. Manufactures state: CAUTION: DO NOT USE ETHYLENE OXIDE STERILIZATION. DO NOT IMMERSE THE SENSOR IN ANY CLEANING SOLUTION, AUTOCLAVE OR EXPOSE THE SENSOR TO HIGH TEMPERATURES. That being the case, how are care givers completely assured they are not contaminated between patients.
If this information is not available through your department, could you direct me to someone who may assist”.

Their reply on July 10th.
To: DHQP Inquiry (NCID/DHQP) (CTR)
Cc: Aydlotte, Susan (CDC/CCHIS/NCHM (CTR)

Below, please find an inquiry from a Medical Equipment Development Company related to patient contamination / infection from the reuse of galvanic oxygen sensors. This inquiry is being escalated because of the technical nature of the question.

Please advise immediately if your group will provide the answer to this inquiry of if the inquiry should be referred elsewhere, for example to a state / local health department, other CDC program, or other Federal agency. Specific guidance on a referral and contact information would be appdreciated.

Programs answering the inquiry should do so by 17 July 2008. If there is a delay, please let us know when to expect the answer so that we can comunicate that information to the inquirer.

Question about this inquiry can be directed to CDC-INFO Correspondence Team by replying to this email or by phone at 601.718.1281. Please reference the service record below and include the Thread Line in your response.

If you contact the inquirer directly, please provide the answer to cdcinfo@cdc.gov so it can be added to the database and limit repeat questions. You may also want to consider adding general information to you website to reduce inquiries.

Thank you for your assistance.

*********************

Comments to my question and the response from the CDC would be greatly appreiciated.

by Frank Dunigan 11 Jul 08, 1005 GMT