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Cheatography

Healthcare - Never Events Cheat Sheet (DRAFT) by [deleted]

Events that never should occur

This is a draft cheat sheet. It is a work in progress and is not finished yet.

Introd­uction to Never Events

Never events are the "kind of mistake that should never happen­" in the field of medical treatment. According to the Leapfrog Group never events are defined as "­adverse events that are serious, largely preven­table, and of concern to both the public and health care providers for the purpose of public accoun­tab­ili­ty."­

Recomm­ended actions following a never event

The Leapfrog Group suggested four actions to be taken following a never event:
1. Apologize to the patient
2. Report the event
3. Perform a root cause analysis
4. Waive costs directly related to the event
 

Never Events (USA)

1. Artificial insemi­nation with the wrong donor sperm or donor egg
2. Unintended retention of a foreign body in a patient after surgery or other procedure
3. Patient death or serious disability associated with patient elopement (disap­pea­rance)
4. Patient death or serious disability associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong prepar­ation or wrong route of admini­str­ation)
5. Patient death or serious disability associated with a hemolytic reaction due to the admini­str­ation of ABO/HL­A-i­nco­mpa­tible blood or blood products
6. Patient death or serious disability associated with an electric shock or elective cardio­version while being cared for in a healthcare facility
7. Patient death or serious disability associated with a fall while being cared for in a healthcare facility
8. Surgery performed on the wrong body part
9. Surgery performed on the wrong patient
10. Wrong surgical procedure performed on a patient
11. Intrao­per­ative or immedi­ately post-o­per­ative death in an ASA Class I patient
12. Patient death or serious disability associated with the use of contam­inated drugs, devices, or biologics provided by the healthcare facility
13. Patient death or serious disability associated with the use or function of a device in patient care, in which the device is used or functions other than as intended
14. Patient death or serious disability associated with intrav­ascular air embolism that occurs while being cared for in a healthcare facility
15. Infant discharged to the wrong person
16. Patient suicide, or attempted suicide resulting in serious disabi­lity, while being cared for in a healthcare facility
17. Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a health care facility
18. Patient death or serious disability associated with hypogl­ycemia, the onset of which occurs while the patient is being cared for in a healthcare facility
19. Death or serious disability (kerni­cterus) associated with failure to identify and treat hyperb­ili­rub­inemia in neonates
20. Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility
21. Patient death or serious disability due to spinal manipu­lative therapy
22. Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contam­inated by toxic substances
23. Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility
24. Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility
25. Any instance of care ordered by or provided by someone impers­onating a physician, nurse, pharma­cist, or other licensed healthcare provider
26. Abduction of a patient of any age
27. Sexual assault on a patient within or on the grounds of the healthcare facility
28. Death or signif­icant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of the healthcare facility