never event
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English
Etymology
The strictest sense, referring to a particularly shocking medical error that should never happen, was the original sense of a never event (circa 2001), although a nuclear power industry publication from the 1980s mentioned a "once-in-a-never event", a collocation playing on such predecessors as once-in-a-blue-moon event and once-in-a-lifetime event.
Noun
never event (plural never events)
- A bad event that should never occur.
- Hypernyms: event, occurrence, happening
- The safety systems engineer examined records of never events across several industries, including health care, air traffic control, and nuclear power.
- 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.
- Hypernyms: event, occurrence, happening
- Wrong-site surgery is a never event because it is always preventable when adequate double checks and crosschecks are enforced.
- 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:
- 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 serious medical errors grouped into seven categories. They include conducting surgery on the wrong site or the wrong patient; killing or seriously injuring someone by giving them the wrong drug; performing artificial insemination with the wrong sperm or egg; the death or serious injury of a mother or newborn during the delivery of a low-risk pregnancy; patient elopement from the hospital; a serious injury or death from the result of falling while in a health care facility; and criminal events such as a patient being sexually or physically assaulted.
- A particularly shocking preventable medical error that should never occur.[1]
- Hypernyms: error, mistake < event, occurrence, happening
- 2003, Laura Davidson, Elizabeth H. Thilo, “How to make kernicterus a "never event"”, in NeoReviews, volume 4, number 11, American Academy of Pediatrics, , pages e308–e314:
- 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 […]