What Are Never Events and Why Do They Matter?
Adam V. Russo | November 6, 2008
Robin J. Fisk, Esq., Fisk Law Firm
Inception by
In 1999, the Institute of Medicine issued a report finding that medical errors were a leading cause of mortality and morbidity in the United States, exceeding deaths attributable to motor vehicle accidents, breast cancer and AIDS.(1) The report, concluding that medi[i]cal errors contributed to 98,000 deaths per year, “ignited public and professional dialog.”(2)
Following this report, in 2002 the National Quality Forum (“NQF”),(3) an organization created to develop quality standards and measure and encourage reporting endorsed a list of 27 serious, largely preventable conditions in which, it claimed should never happen to a hospital patient.(4) A 28th was added in 2006. The list included preventable errors arising from surgery, medical devices or products; inadequate patient protection; inadequate care management; unclean or unsafe environmental conditions; or criminal acts. The intent was to create national consensus around a common set of adverse events which needed to be investigated, analyzed for root cause and reported any time they occur – and the list was the start. (more…)
