Never Events in Surgery

Abstract

Introduced by Dr. Ken Kizer in 2001, the concept of the “never event” has pervaded patient quality and safety initiatives over the last two decades. “Never events” are defined as egregious medical errors that should be wholly avoidable such that they never occur, for example, wrong-site surgery or leaving a foreign body in a patient. These events can not only be costly to patients, mentally, and financially, they also pose a serious burden to the healthcare system at large with some estimates exceeding $29 billion per year. In response, the Centers for Medicare and Medicaid Services has deemed many of these events “nonreimbursable,” holding hospitals accountable and driving a push for quality improvement nationally. Unfortunately, the term “never event” remains a misnomer as these errors still occur today. Significant effort is still underway to study and improve upon their prevention. Targeted protocols, evolving workplace cultures, and advancing technologies have all contributed to reducing errors since these events have been brought to light. While “never events” are still reported every year, there have been impressive strides toward their reduction, and as efforts continue, they may yet be eliminated altogether.