Return to Never Events Collaborative
Never Events
  Medicare
HAC
  
NQF
Serious
Reportable Events
Surgical Events   x
   1) Surgery performed on the wrong body part    x
   2) Surgery performed on the wrong patient  x
   3) Wrong surgical procedure performed on patient    x
   4) Unintended retention of a foreign object in a patient x x
   5) Artificial insemination with the wrong sperm or donor egg x
   6) Intraoperative or immediately postoperative death in an
   American Society of Anesthesiologist Class I Patient 
  x
Product or Device Events    
   7) Patient death or disability associated with use of  
   contaminated drugs, devices, or biologics provided by
   the healthcare facility
x
    8) Patient death or serious disability associated with the
   use or function of a device in patient care, in which the
   device is used for functions other than as intended
  x
   9) Patient death or serious disability associated with
   intravascular air embolism that occurs while being cared
   for in a health care facility
x x
Patient Protective Events    
   10) Infant discharged to the wrong person    x
   11) Patient death or serious disability associated with
   patient elopement (disappearance) 
  x
   12) Patient suicide, or attempted suicide resulting in serious
   disability, while being cared for in a health care facility 
  x
Case Management Events    
    13) Patient death or serious disability associated with a
   medication error (eg, errors involving the wrong drug,
   wrong dose, wrong patient, wrong time, wrong rate,
   wrong preparation, or wrong route of administration)
  x
  14) Patient death or serious disability associated with a
   hemolytic reaction due to the administration of ABO/HLA-
   incompatible blood or blood products 
x x
   15) Maternal death or serious disability associated with
   labor or delivery in a low-risk pregnancy while being cared
   for in a health care facility 
  x
   16) Patient death or serious disability associated with
   hypoglycemia, the onset of which occurs while the patient
   is being cared for in a health care facility
x x
   17) Death or serious disability (kernicterus) associated with 
   failure to identify and treat hyperbilirubinemia in neonates 
  x
   18) Stage 3 or 4 pressure ulcers acquired after admission
   to a health care facility
x x
   19) Patient death or serious disability due to spinal
   manipulative therapy
  x
Environmental Events    
   20) Patient death or serious disability associated with an
   electric shock or electrical cardioversion while being cared
   for in a health care facility 
  x
   21) Any incident in which a line designated for oxygen or
   other gas to be delivered to a patient contains the wrong
   as or is contaminated by toxic substances
  x
    22) Patient death or serious disability associated with a
   burn incurred from any source while being cared for in a
   health care facility
  x
    23) Patient death or serious disability associated with a fall
   while being cared for in a health care facility
x x
    24) Patient death or serious disability associated with the
   use of restraints or bedrails while being cared for in a
   health care facility
  x
Criminal Events    
   25) Any instance of care ordered by or provided by
   someone impersonating a physician, nurse, pharmacist,
   or other licensed health care provider 
  x
   26) Abduction of a patient of any age    x
   27) Sexual assault on a patient within or on the grounds
   of the health care facility 
  x
   28) Death or significant injury of a patient or staff member
   resulting from a physical assault (ie, battery) that occurs
   within or on the grounds of the health care facility 
  x
     
Medicare HAC's Not Classified as Severe Reportable Events by NQF
  1)  Catheter-Associated Urinary Tract Infections  x  
  2)  Vascular Catheter-Associated Infection x  
  3)  Manifestations of Poor Glycemic Control (Diabetic
   Ketoacidosis, Nonketotic Hyperosmolar Coma, Hypoglycemic
   Coma, Secondary Diabetes with Ketoacidosis, Secondary
   Diabetes with Hyperosmolarity)
x  
   4)  Deep Vein Thrombosia/Pulmary Embolism
   in total knee replacement and hip replacement.
x  
   5)  Surgical Site Infections in Coronary Artery Bypass Graft,
   Gastroenterostomy, Laparoscopic gastric restrictive surgery
   and  certain orthopedic procedures (spine, neck, shoulder,
   elbow)  
      
x