Patient suicide, attempted suicide, or self-harm resulting in serious disability, while being cared for in a health care facility Patient death or serious disability associated with patient elopement (disappearance) Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a health care settingĭischarge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person Patient death or serious injury associated with the use or function of a device in patient care, in which the device is used for functions other than as intended Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the health care setting Intraoperative or immediately postoperative/postprocedure death in an American Society of Anesthesiologists Class I patient Unintended retention of a foreign object in a patient after surgery or other procedure Wrong surgical or other invasive procedure performed on a patient Surgery or other invasive procedure performed on the wrong patient Surgery or other invasive procedure performed on the wrong body part

National Quality Forum List of Serious Reportable Events, 2016 Since the initial never event list was developed in 2002, it has been revised multiple times, and now consists of 29 'serious reportable events' grouped into 7 categories: Over time, the term's use has expanded to signify adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable. The term 'Never Event' was first introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF), in reference to particularly shocking medical errors-such as wrong-site surgery-that should never occur.

Sentinel event