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In 2002, the National Quality Forum (NQF) defined 27 “never events” that pose serious harm to patients and are considered preventable. Formally, they are called “Serious Reportable Events” or “Sentinal Events.” The number of events was revised to 29 in 2011, the most current list, and includes events such as wrong-site surgery, retention of a foreign object in a patient after surgery, and patient death or serious injury associated with an air embolism. To see the complete list, click here.

In 2013, The Joint Commission’s top ten most frequently reviewed sentinel event categories were:

  • Delay in treatment
  • Wrong patient, wrong site, wrong procedure
  • Unintended retention of a foreign body
  • Suicide
  • Fall
  • Other unanticipated event
  • Op/post-op complication
  • Criminal event
  • Medication error
  • Perinatal death/injury

This month’s civil topic is Serious Reportable Events (“never events”). Topics covered are:

  • “Never event” defined (6/2/14)
  • Reporting Requirements (6/9/14)
  • Finding the root of the problem (6/16/14)
  • Legal implications (6/23/14)

Note: To see all posts in this topic, click here.



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