Never Events2019-01-24T17:00:07+00:00

Quick Facts:

“Never” Events are the most egregious type of errors that should never happen. Ranging from surgery in the wrong site to criminal maliciousness. 

After a cautious and rigorous analysis of national malpractice claims, Johns Hopkins patient safety researchers estimate that a surgeon in the United States leaves a foreign object such as a sponge or a towel inside a patient’s body after an operation 39 times a week, performs the wrong procedure on a patient 20 times a week and operates on the wrong body site 20 times a week.

The researchers, reporting online in the journal Surgery, say they estimate that 80,000 of these so-called “never events” occurred in American hospitals between 1990 and 2010 — and believe their estimates are likely on the low side.

In the same study, it is found that Death occurred in 6.6 percent of patients, permanent injury in 32.9 percent and temporary injury in 59.2 percent.

Source: Johns Hopkins University

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In December of 2012, Johns Hopkins University released a Report identifying several categories of completely preventable medical mistakes known as “Never Events.”  A Never Event is an inexcusable error that never should occur.


   The following categories of shocking, extreme and indefensible Never Events include:

  • Wrong Site Surgeries
    • This occurs when a surgeon operates on the wrong part of the patient’s body. For example, if a patient is scheduled for a right knee replacement and the surgeon operates on the left knee.
  • Wrong Surgery is Performed
    • This occurs when a surgeon performs the wrong surgery on a patient. For example, a patient is scheduled for a knee replacement and the surgeon performs a hip replacement.
  • Retained Foreign Object
    • This occurs when a surgical instrument, a towel or a sponge, is left inside the patient’s body.
  • Patient Care Management
    • This occurs when the wrong type of medication or blood product is administered and causes harm to the patient.
  • Patient Protection
    • This occurs when a patient who is unable to care for himself/herself is released to someone other than an authorized person and the patient is subsequently injured, disabled or even dies.
  • Environmental
    • These events include electrical shock, oxygen lines that contain no gas or the wrong gas, burn injuries, and the use of bed restraints that result in serious patient injury or death.
  • Radiologic
    • This occurs when a metal object is introduced into the MRI area and results in patient injury.
  • Criminal
    • This occurs when medical treatment is provided by someone who is impersonating a healthcare professional, when a patient is abducted or when a patient is physically or sexually abused.


Never Events are not as rare as one may think.  According to Johns Hopkins University, an estimated 80,000 Never Events occurred in US hospitals between 1990 and 2010.  During this time period:

  • The wrong surgical procedure was performed on patients an estimated 20 times per week.
  • The wrong body part was operated on by surgeons an estimated 20 times per week.
  • A foreign object, such as a surgical instrument, a surgical towel or a surgical sponge was left in patients an estimated 40 times per week.

Patients between 40-49 were the most vulnerable for a Never Event.  Also, the most Never Event mistakes were made by surgeons less than 60 years old.

Sadly, these Never Events continue to occur today at the rate of approximately 4,000 new cases each year.  These lapses in medical care which are unambiguous, preventable and clearly identifiable represent a major healthcare quality problem that causes needless injury and millions of dollars in otherwise unnecessary medical care each year.

Again, “Never Events” are totally preventable medical mistakes. If you or a loved one has suffered a “Never Event,” call our knowledgeable and experienced office today.