never event

Noun

never event (plural never events)

1. A bad event that should never occur.
   • The safety systems engineer examined records of never events across several industries, including health care, air traffic control, and nuclear power.
   1. A serious adverse medical event that should never occur and thus is, by strict definitions of preventability, always preventable, being unambiguous, clearly identifiable and measurable, and resulting in death or significant disability.
      • Wrong-site surgery is a never event because it is always preventable when adequate double checks and crosschecks are enforced.
      • When never event was coined in 2001, it originally referred only to the most extreme medical errors. But over the past two decades, the phrase has come to encompass, more broadly, any severe adverse medical result that should have been preventable. In the U.S., never events are defined as 29...2024 December 9, Rachel Nuwer, “How Did a Surgeon in Florida Mistake a Man's Liver for His Spleen? Grave errors like this, called never events, aren't as rare as they might seem”, in New York Magazine
   2. A particularly shocking preventable medical error that should never occur.
      • Kernicterus has been called a “never event,” identified on a list of “serious, egregious, preventable adverse events” by The Agency for Healthcare Research and Quality […]2003, Laura Davidson, Elizabeth H. Thilo, “How to make kernicterus a "never event"”, in NeoReviews, volume 4, number 11, American Academy of Pediatrics, →DOI, pages e308–e314