Management viva: Never Events
‘Never events’ are incidences which are considered unacceptable and eminently preventable.
The term ‘never events’ was first introduced in 2001 by ken Kizer, former chief executive of the National Quality Forum, in the United States, in reference to particularly shocking medical errors that should never occur.
The information from the United States indicates that the use of the term and its associated focus has improved safety. In the UK, the term was introduced in April 2009.
An incident must fulfil the following criteria, to be a never event:
- It has clear potential for, or has caused, severe harm or death.
- There is evidence that is has occurred in the past.
- There is existing national guidance or safety recommendations on how it can be prevented and there is support for implementing these.
- It can be easily defined, identified and continually measured.
Examples of never events related to the Emergency Department
- Misplaced naso-gastric or oro-gastric tube not detected prior to use
- Intravenous administration of mis-selected concentrated potassium chloride
- Retain foreign object post operation such as retention of guide wire post central venous access insertion.
- Wrongly prepared high risk injectable such as midazolam , heparin or ketamine
- Maladministration of insulin
- Overdose of midazolam during conscious sedation
- Opiate overdose of an opioid naive patient
- Entrapment in bedrails
- Fall from unrestricted windows
- Transfusion of ABO incompatible blood components
- Wrong gas administered or failure to administer any gas
- Failure to monitor and respond to oxygen saturation
- Introduction of air embolism after the insertion of central venous catheter, through the line, and during its removal.
- Misidentification of patients
- Severe scalding of patients
Links to the Royal College of Emergency Medicine document on never events
Edited by Dr T Hassan