From: Clarifying "never events" and introducing "always events"
1. | Surgery performed on the wrong body part. |
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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. |