Understanding never events: unacceptable failures in patient safety

The concept of ‘never events’ is described broadly as serious and largely preventable incidents that should never occur in healthcare settings if proper safety protocols are followed. Category General Falls from poorly restricted windows Chest or neck entrapment in bed rails Misplaced naso- or oro-gastric tubes Scalding of patients Unintentional connection of a patient requiring oxygen to an air flowmeter Undetected oesophageal intubation Transfusion or transplantation of ABO-incompatible blood components or organs Medication Mis-selection of high-strength midazolam during conscious sedation Overdose of methotrexate for non-cancer treatment Overdose of insulin due to abbreviations or incorrect device Administration of medication by the wrong route Mis-selection of a strong potassium solution Mis-selection of a strong potassium solution Surgery Wrong site surgery Wrong implant/prosthesis Retained foreign object post-procedure Mental Health Failure to install functional collapsible shower or curtain rails What does one do after a never event? Studies reveal that never events persist at a rate of 1 to 2 per 100 incidents, with overall patient safety incidents occurring in 2 to 3 out of every 100 consultations. While never events emphasises preventable harm within healthcare systems, in India, similar incidents are categorised and addressed under the broader legal framework of medical negligence.