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Table 1 Serious reportable events ("never-events"), as defined by the National Quality Forum (NQF consensus report, update 2006; http://www.qualityforum.org)

From: Clarifying "never events" and introducing "always events"

1. Surgery performed on the wrong body part.
2. Surgery performed on the wrong patient.
3. Wrong surgical procedure performed on a patient.
4. Unintended retention of a foreign object in a patient after surgery or other procedure.
5. Intraoperative or immediate postoperative death in an ASA class I patient.
6. Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility.
7. 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.
8. Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility.
9. Infant discharged to the wrong person.
10. Patient death or serious disability associated with patient elopement (disappearance)
11. Patient suicide, or attempted suicide, resulting in serious disability while being cared for in a healthcare facility.
12. Patient death or serious disability associated with a medication error.
13. Patient death or serious disability associated with a haemolytic reaction due to the administration of ABO/HLA-incompatible blood or blood products.
14. Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare facility.
15. Patient death or serious disability associated with hypoglycaemia, the onset of which occurs while the patient is being cared for in a healthcare facility.
16. Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates.
17. Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility.
18. Patient death or serious disability due to spinal manipulative therapy.
19. Artificial insemination with wrong donor sperm or wrong egg.
20. Patient death or serious disability associated with an electric shock while being cared for in a healthcare facility.
21. 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 with toxic substances.
22. Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility.
23. Patient death or serious disability associated with a fall while being cared for in a healthcare facility.
24. Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility.
25. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider.
26. Abduction of a patient of any age.
27. Sexual assault on a patient within or on the grounds of a healthcare facility.
28. 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 a healthcare facility.