RESEARCH STARTER
Never events
Never events are serious, preventable errors or incidents that occur within the healthcare system, potentially leading to severe patient harm or death. Coined in 2001 by physician Ken Kizer, the term refers to medical mistakes that should never happen, emphasizing the need for heightened patient safety measures. As of 2011, there are seven main categories of never events, which encompass a total of twenty-nine specific incidents. These categories include surgical errors, product or device mishaps, radiologic incidents, environmental hazards, patient protection failures, care management mistakes, and criminal acts against patients.
Notable examples of never events include surgeries performed on the wrong body part or patient, incorrect medication administration, and environmental dangers like burns or electrical shocks. Although never events are rare, they are taken seriously, prompting thorough investigations and root cause analyses when they occur. Healthcare providers are expected to disclose errors, apologize, and often waive costs associated with the affected procedures. The medical community continues to advocate for improved standards to prevent these events, acknowledging the balance between their rarity and the critical need for patient safety.
Authored By: Dziak, Mark 1 of 4
Published In: 2024 2 of 4
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- Related Articles:'Never events': the mistakes every nurse dreads making during their career: Never events can cause serious harm or even a patient death. While many are surgical errors, some common nursing tasks have the potential for serious consequences.;Insulin administration: the risks and tips on how to prevent errors: Insulin errors can cause severe hypoglycaemia in people with diabetes. Experts explain 'never events' and how to ensure your practice is safe.;Maximising learning from patient safety incidents in emergency care.;Never events: nurses alone at night in high-security wards: Nurses at a high-security psychiatric hospital were left alone on night shifts nearly 200 times last year, board papers reveal.;Never events: the mistakes no-one wants to make: A never event can cause serious harm or even patient death. While many are surgical errors, some common nursing tasks, such as insulin, blood transfusion or medication administration errors, have the potential for serious consequences – at great cost to patients and the NHS
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Full Article
Never events are serious errors, oversights, and crimes that occasionally take place in the healthcare industry and can cause serious injury or death to patients. As the term suggests, these events should never be allowed to occur. Historically, there were seven main categories of never events that are broken down into a total of twenty-nine specific reportable events.In 2025, the National Quality Forum (NQF) revised the list to twenty-eight events classified under four primary categories. While rare, never events are the subject of serious investigation and calls for improvement.
Definition of Never Events
Ken Kizer, a physician and former chief executive officer of the National Quality Forum (NQF), coined the term never event in 2001. In its first usages, the term referred to serious medical errors that should never be allowed to happen. The NQFis a nonprofit organization that places improving healthcare outcomes, ensuring safety, and delivering affordability as its core goals, while supporting patient rights and protections. It conducted studies of such medical errors and reported its findings in the hopes of drawing attention to never events and creating new safeguards against them.
By 2002, the NQF compiled a list of never events. The concept began spreading and gained greater acceptance by the medical community and the public. Over time, the concept expanded to include a wider range of harmful events experienced by patients. These events had to fit three criteria: they had to be serious enough to result in a patient’s death or disability, clear enough to identify and measure (unambiguous), and potentially avoidable (preventable), while also meeting additional public-accountability and safety-system criteria.
Categories and Events
The NQF modified its list of never events in 2011 to include twenty-nine specific events divided into seven main categories. These remained in place until 2025s. In 2025, NQF updated the Serious Reportable Events list and announced alignment with the Joint Commission in January 2026. These events cover a wide range of patient experiences and medical personnel actions before, during, and after medical procedures. The categories include surgical events, product or device events, radiologic events, environmental events, patient protection events, care management events, and criminal events.
One of the main categories of never events involves surgical procedures. Surgery is a delicate and complicated task. If performed improperly, it can lead to an array of hazards for patients. Some of these hazardous events include surgeries performed on the wrong patient, surgeries performed on the wrong body part, or incorrect surgical procedures performed. Another risk involving surgeries includes retained objects or surgical tools, such as towels or sponges being accidentally left inside a patient’s body.
Medical products and devices also contribute to never events. Risks include medical machines and tools being used incorrectly or for purposes other than those intended. This category also extends to hazards from medication and other drugs, which can become contaminated and pose risks or harmful side effects. Harm that occurs during a procedure that uses MRI (magnetic resonance imaging) technology is categorized as a radiologic event.
Patient harm that occurs due to the physical surroundings of a healthcare establishment falls under the category of environmental never events. During care, patients may receive burns or electric shocks that can cause death or serious injury. In addition, lines carrying oxygen or other gases may be contaminated or used incorrectly and result in various hazards. Sometimes, even seemingly innocuous environmental features such as bed rails employed improperly could contribute to never events.
Healthcare providers have a responsibility to provide reasonable protection to their patients. Failing to do so may lead to never events in the patient protection category. For example, these events may occur if patients are released from care when they are unable to make decisions or if patients disappear from a healthcare facility. The most serious breach of patient protection involves a patient attempting or committing suicide within a healthcare facility.
The care management category is also related to patient protection, but it involves a wider range of cases. These cases may involve errors in medications and prescriptions, failure to communicate test results, or loss or misuse of specimens. In some state reporting systems, the most common care management event (exact percentage may vary by place and year) involved instances of caretaker neglect leading to pressure ulcers or bedsores (also called pressure injuries), serious skin injuries that often occur among bedridden people. Patients sustaining injury or death during falls accounted for a significant percentage of cases. These are also part of the care management category.
The final category of never events involves criminal acts perpetrated against patients in healthcare facilities. These cases may range from sexual abuse to physical assault against patients, as well as the abduction of patients. In addition, any actions taken by people falsely impersonating healthcare personnel, such as doctors or nurses, fall into the category of criminal events.
Responses and Rarity
Generally, when never events occur, authorities perform a root cause analysis, an in-depth examination of the event and factors that contributed to it, which includes reporting the event, analyzing its causes, and taking corrective action. Based on these findings, offenders usually are expected to disclose their errors and officially report them to medical authorities; however, the reporting rules vary by state, accreditor, and event type. Offenders typically apologize to patients and their loved ones and waive any costs related to the medical procedure in question. In many events—particularly criminal ones—legal action also becomes an important factor.
Leapfrog’s 2025 Never Events policy requires hospitals to take nine actions after a never event, including apology, reporting, root-cause analysis, waiving direct costs, interviewing patients or families, informing them of prevention steps, supporting caregivers, making the policy available on request, and annual review.
Never events can be severe and tragic. Some individuals and organizations have called for stringent standards to eradicate all never events from medical procedures. Despite these strong reactions to never events, medical experts point out that such events are not common. While about four thousand surgical never events take place annually in the United States (a frequently cited 2013 study), that figure should be measured against the millions of procedures medical practitioners perform correctly.
The Global Patient Safety Action Plan 2021–2030 has an outline for governments, health systems, and other stakeholders to work together and implement patient safety initiatives in a comprehensive manner.
Bibliography
Adverse Health Events in Minnesota: Annual Public Report—2024. Minnesota Department of Health, www.health.state.mn.us/facilities/patientsafety/adverseevents/docs/2024ahereport.pdf. Accessed 21 Mar. 2026.
“Joint Commission and NQF Aligning Serious Reportable Events and Sentinel Events Lists.” The Joint Commission, 26 Jan. 2026, www.jointcommission.org/en-us/knowledge-library/news/2026-01-joint-commission-and-nqf-aligning. Accessed 21 Mar. 2026.
Lembitz, Alan, and Ted J. Clarke. “Clarifying ‘Never Events’ and Introducing ‘Always Events.’” Patient Safety in Surgery, vol. 3, 2009, article 26, doi:10.1186/1754-9493-3-26. Accessed 21 Mar. 2026.
2025 Never Events Fact Sheet. The Leapfrog Group, Mar. 2025, www.ratings.leapfroggroup.org/sites/default/files/2025-03/2025%20Never%20Events%20Fact%20Sheet.pdf. Accessed 21 Mar. 2026.
“Patient Safety.” World Health Organization, www.who.int/news-room/fact-sheets/detail/patient-safety. Accessed 21 Mar. 2026.
“Sentinel Event.” Joint Commission, www.jointcommission.org/sentinel_event.aspx. Accessed 21 Mar. 2026.
Sotoodeh, Mani et al. “A Comprehensive and Improved Definition for Hospital-Acquired Pressure Injury Classification Based on Electronic Health Records: Comparative Study.” JMIR Medical Informatics, vol. 11, 23 Feb. 2023, doi:10.2196/40672. Accessed 21 Mar. 2026.
“Updating the Serious Reportable Events (SRE) List.” National Quality Forum, www.qualityforum.org/en-us/key-initiatives/updating-the-serious-reportable-events-sre-list. Accessed 21 Mar. 2026.
Zaslow, Joanna, et al. “The Problem with ‘Never Events’.” BMJ Quality & Safety, vol. 33, no. 9, 2024, pp. 613–17, doi:10.1136/bmjqs-2023-016981. Accessed 21 Mar. 2026.
Full Article
Never events are serious errors, oversights, and crimes that occasionally take place in the healthcare industry and can cause serious injury or death to patients. As the term suggests, these events should never be allowed to occur. Historically, there were seven main categories of never events that are broken down into a total of twenty-nine specific reportable events.In 2025, the National Quality Forum (NQF) revised the list to twenty-eight events classified under four primary categories. While rare, never events are the subject of serious investigation and calls for improvement.
Definition of Never Events
Ken Kizer, a physician and former chief executive officer of the National Quality Forum (NQF), coined the term never event in 2001. In its first usages, the term referred to serious medical errors that should never be allowed to happen. The NQFis a nonprofit organization that places improving healthcare outcomes, ensuring safety, and delivering affordability as its core goals, while supporting patient rights and protections. It conducted studies of such medical errors and reported its findings in the hopes of drawing attention to never events and creating new safeguards against them.
By 2002, the NQF compiled a list of never events. The concept began spreading and gained greater acceptance by the medical community and the public. Over time, the concept expanded to include a wider range of harmful events experienced by patients. These events had to fit three criteria: they had to be serious enough to result in a patient’s death or disability, clear enough to identify and measure (unambiguous), and potentially avoidable (preventable), while also meeting additional public-accountability and safety-system criteria.
Categories and Events
The NQF modified its list of never events in 2011 to include twenty-nine specific events divided into seven main categories. These remained in place until 2025s. In 2025, NQF updated the Serious Reportable Events list and announced alignment with the Joint Commission in January 2026. These events cover a wide range of patient experiences and medical personnel actions before, during, and after medical procedures. The categories include surgical events, product or device events, radiologic events, environmental events, patient protection events, care management events, and criminal events.
One of the main categories of never events involves surgical procedures. Surgery is a delicate and complicated task. If performed improperly, it can lead to an array of hazards for patients. Some of these hazardous events include surgeries performed on the wrong patient, surgeries performed on the wrong body part, or incorrect surgical procedures performed. Another risk involving surgeries includes retained objects or surgical tools, such as towels or sponges being accidentally left inside a patient’s body.
Medical products and devices also contribute to never events. Risks include medical machines and tools being used incorrectly or for purposes other than those intended. This category also extends to hazards from medication and other drugs, which can become contaminated and pose risks or harmful side effects. Harm that occurs during a procedure that uses MRI (magnetic resonance imaging) technology is categorized as a radiologic event.
Patient harm that occurs due to the physical surroundings of a healthcare establishment falls under the category of environmental never events. During care, patients may receive burns or electric shocks that can cause death or serious injury. In addition, lines carrying oxygen or other gases may be contaminated or used incorrectly and result in various hazards. Sometimes, even seemingly innocuous environmental features such as bed rails employed improperly could contribute to never events.
Healthcare providers have a responsibility to provide reasonable protection to their patients. Failing to do so may lead to never events in the patient protection category. For example, these events may occur if patients are released from care when they are unable to make decisions or if patients disappear from a healthcare facility. The most serious breach of patient protection involves a patient attempting or committing suicide within a healthcare facility.
The care management category is also related to patient protection, but it involves a wider range of cases. These cases may involve errors in medications and prescriptions, failure to communicate test results, or loss or misuse of specimens. In some state reporting systems, the most common care management event (exact percentage may vary by place and year) involved instances of caretaker neglect leading to pressure ulcers or bedsores (also called pressure injuries), serious skin injuries that often occur among bedridden people. Patients sustaining injury or death during falls accounted for a significant percentage of cases. These are also part of the care management category.
The final category of never events involves criminal acts perpetrated against patients in healthcare facilities. These cases may range from sexual abuse to physical assault against patients, as well as the abduction of patients. In addition, any actions taken by people falsely impersonating healthcare personnel, such as doctors or nurses, fall into the category of criminal events.
Responses and Rarity
Generally, when never events occur, authorities perform a root cause analysis, an in-depth examination of the event and factors that contributed to it, which includes reporting the event, analyzing its causes, and taking corrective action. Based on these findings, offenders usually are expected to disclose their errors and officially report them to medical authorities; however, the reporting rules vary by state, accreditor, and event type. Offenders typically apologize to patients and their loved ones and waive any costs related to the medical procedure in question. In many events—particularly criminal ones—legal action also becomes an important factor.
Leapfrog’s 2025 Never Events policy requires hospitals to take nine actions after a never event, including apology, reporting, root-cause analysis, waiving direct costs, interviewing patients or families, informing them of prevention steps, supporting caregivers, making the policy available on request, and annual review.
Never events can be severe and tragic. Some individuals and organizations have called for stringent standards to eradicate all never events from medical procedures. Despite these strong reactions to never events, medical experts point out that such events are not common. While about four thousand surgical never events take place annually in the United States (a frequently cited 2013 study), that figure should be measured against the millions of procedures medical practitioners perform correctly.
The Global Patient Safety Action Plan 2021–2030 has an outline for governments, health systems, and other stakeholders to work together and implement patient safety initiatives in a comprehensive manner.
Bibliography
Adverse Health Events in Minnesota: Annual Public Report—2024. Minnesota Department of Health, www.health.state.mn.us/facilities/patientsafety/adverseevents/docs/2024ahereport.pdf. Accessed 21 Mar. 2026.
“Joint Commission and NQF Aligning Serious Reportable Events and Sentinel Events Lists.” The Joint Commission, 26 Jan. 2026, www.jointcommission.org/en-us/knowledge-library/news/2026-01-joint-commission-and-nqf-aligning. Accessed 21 Mar. 2026.
Lembitz, Alan, and Ted J. Clarke. “Clarifying ‘Never Events’ and Introducing ‘Always Events.’” Patient Safety in Surgery, vol. 3, 2009, article 26, doi:10.1186/1754-9493-3-26. Accessed 21 Mar. 2026.
2025 Never Events Fact Sheet. The Leapfrog Group, Mar. 2025, www.ratings.leapfroggroup.org/sites/default/files/2025-03/2025%20Never%20Events%20Fact%20Sheet.pdf. Accessed 21 Mar. 2026.
“Patient Safety.” World Health Organization, www.who.int/news-room/fact-sheets/detail/patient-safety. Accessed 21 Mar. 2026.
“Sentinel Event.” Joint Commission, www.jointcommission.org/sentinel_event.aspx. Accessed 21 Mar. 2026.
Sotoodeh, Mani et al. “A Comprehensive and Improved Definition for Hospital-Acquired Pressure Injury Classification Based on Electronic Health Records: Comparative Study.” JMIR Medical Informatics, vol. 11, 23 Feb. 2023, doi:10.2196/40672. Accessed 21 Mar. 2026.
“Updating the Serious Reportable Events (SRE) List.” National Quality Forum, www.qualityforum.org/en-us/key-initiatives/updating-the-serious-reportable-events-sre-list. Accessed 21 Mar. 2026.
Zaslow, Joanna, et al. “The Problem with ‘Never Events’.” BMJ Quality & Safety, vol. 33, no. 9, 2024, pp. 613–17, doi:10.1136/bmjqs-2023-016981. Accessed 21 Mar. 2026.
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- Insulin administration: the risks and tips on how to prevent errors: Insulin errors can cause severe hypoglycaemia in people with diabetes. Experts explain 'never events' and how to ensure your practice is safe.Published In: Emergency Nurse, 2025, v. 33, n. 6. P. 8Authored By: Amara, PavanPublication Type: Academic Journal
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- Never events: nurses alone at night in high-security wards: Nurses at a high-security psychiatric hospital were left alone on night shifts nearly 200 times last year, board papers reveal.Published In: Mental Health Practice, 2026, v. 29, n. 3. P. 6Authored By: Stacey, AlisonPublication Type: Academic Journal
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