There is much in the medical news these days about Medicare’s plan to deny payment for certain “never events”. A never event is one that is both preventable and should never happy in any circumstance. The National Quality Forum lists 28 “never events”. They have to be clearly identifiable, preventable, and serious in their consequences for patients, and indicate a real problem in the safety and credibility of a health-care facility. The list is used by Centers for Medicare & Medicaid Services.

• Unintended retention of a foreign object in a patient after surgery or other procedure
  
• Patient death or serious disability associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of administration)
  
• Patient death or serious disability due to incompatible blood or blood products
  
• Patient death or serious disability associated with an electric shock in a health-care facility
  
• Patient death or serious disability associated with a fall while being cared for in a health-care facility
  
• Surgery performed on the wrong body part
  
• Surgery performed on the wrong patient
  
• Wrong surgical procedure performed on a patient
  
• Intraoperative or immediately post-operative death in an otherwise healthy patient
  
• Patient death or serious disability associated with the use of contaminated drugs, devices, provided by the health-care facility
  
• Patient death or serious disability associated with the use or function of a device in patient care, in which the device is used or functions other than as intended
  
• Patient death or serious disability associated with intravascular air embolism that occurs in a health-care facility
  
• Infant discharged to the wrong person
  
• Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a health-care facility
  
• Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a health-care facility
  
• Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a health-care facility
  
• Death or serious disability associated with failure to identify and treat hyperbilirubinemia in neonates
  
• Stage 3 or 4 pressure ulcers acquired after admission to a health-care facility
  
• Patient death or serious disability due to spinal manipulative therapy
  
• Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances
  
• Patient death or serious disability associated with a burn incurred from any source while being cared for in a health-care facility
  
• Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a health-care facility
  
• Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health-care provider
  
• Abduction of a patient of any age
  
• Sexual assault on a patient within or on the grounds of the health-care facility
  
• Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of the health-care facility
  
• Artificial insemination with the wrong donor sperm or donor egg
  
• Patient death, serious disability associated with patient disappearance