AHRQ Patient Safety Network

The Collection > Never Events

PATIENT SAFETY PRIMERS
Never Events

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Never Events : The list of never events has expanded over time to include adverse events that are unambiguous, serious, and usually preventable... Read Full Glossary Entry >

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•Device-related Complications (1)

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•Journal Article (18)

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•Epidemiology of Errors and Adverse Events (13)

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Approach to Improving Safety
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Never Events

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•Medicine (33)

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•Health Care Providers (22)

•Health Care Executives and Administrators (39)

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•Hospitals (37)

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1 - 20 of 46

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STUDY

The $17.1 billion problem: the annual cost of measurable medical errors.

Van Den Bos J, Rustagi K, Gray T, Halford M, Ziemkiewicz E, Shreve J. Health Aff (Millwood). 2011;30:596-603.

MULTI-USE WEBSITE

HAC Posting on Hospital Compare.

Centers for Medicare & Medicaid Services.

NEWSPAPER/MAGAZINE ARTICLE

NY Medicaid ups the ante: by refusing to pay for 14 'never events,' the nation's biggest Medicaid program could propel other states into action.

DerGurahian J. Mod Healthc. June 16, 2008;38:6.

NEWSPAPER/MAGAZINE ARTICLE

Minnesota is first state with policy to stop billing after medical errors.

Lerner M. Star Tribune. September 18, 2007;News section:5B.

NEWSPAPER/MAGAZINE ARTICLE

Many Mass. hospitals will pay for errors.

Kowalczyk L. Boston Globe. September 17, 2007;Metro section:1A.

NEWSPAPER/MAGAZINE ARTICLE

'Never' land.

Carpenter D. Hosp Health Netw. November 2007;81:34-38.

BOOK/REPORT

To Err Is Human—But Don't Expect to Get Paid For It.

ASQ Quarterly Quality Report. Milwaukee, WI: American Society of Quality; October 2008.

BOOK/REPORT

Adverse Events in Hospitals: Overview of Key Issues.

Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-07-00470.

BOOK/REPORT

Adverse Events in Hospitals: Care Study of Incidence Among Medicare Beneficiaries in Two Selected Counties.

Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-08-00220.

BOOK/REPORT

2009 Utah Sentinel Events Data Report.

Salt Lake City, UT: Utah Department of Health, Utah Hospitals & Health Systems Association, and HealthInsight; March 10, 2010.

NEWSPAPER/MAGAZINE ARTICLE

More states shred bills for awful medical errors: patients in 23 states will no longer pay for certain mistakes, hospitals say.

Aleccia J. MSNBC News. August 12, 2008.

STUDY

To make or buy patient safety solutions: a resource dependence and transaction cost economics perspective.

Fareed N, Mick SS. Health Care Manage Rev. 2011;36:288-298.

STUDY

Potential unintended consequences due to Medicare's "No Pay for Errors Rule"? A randomized controlled trial of an educational intervention with internal medicine residents.

Mookherjee S, Vidyarthi AR, Ranji SR, Maselli J, Wachter RM, Baron RB. J Gen Intern Med. 2010;25:1097-1101.

BOOK/REPORT classic

Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries.

Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; November 2010. Report No. OEI-06-09-00090.

STUDY

Venous thromboembolism after trauma: a never event?

Thorson CM, Ryan ML, Van Haren RM, et al. Crit Care Med. 2012;40:2967-2973.

BOOK/REPORT classic

The Economic Measurement of Medical Errors.

Shreve J, van Den Bos J, Gray T, Halford M, Rustagi K, Ziemkiewicz E. Schaumburg, IL: The Society of Actuaries; 2010.

NEWSPAPER/MAGAZINE ARTICLE

Avoidable mistakes rise despite hospital efforts.

Colliver V. San Francisco Chronicle. June 2, 2010;A1.

COMMENTARY

CMS's hospital-acquired condition lists link hospital payment, patient safety.

Clancy CM. Am J Med Qual. 2009;24:166-168.

NEWSPAPER/MAGAZINE ARTICLE

No pay for "never event" errors becoming standard.

O'Reilly KB. American Medical News. January 7, 2008.

STUDY

The relationship between organizational leadership for safety and learning from patient safety events.

Ginsburg LR, Chuang YT, Berta WB, et al. Health Serv Res. 2010;45:607-632.

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