Patient or staff death or serious injury associated with a burn incurred from any source in the course of a patient care process in a health care setting.Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains no gas, the wrong gas, or is contaminated by toxic substances.Patient or staff death or serious disability associated with an electric shock in the course of a patient care process in a health care setting.Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results.Patient death or serious disability resulting from the irretrievable loss of an irreplaceable biological specimen.Artificial insemination with the wrong donor sperm or wrong egg.Any stage 3, stage 4, or unstageable pressure ulcers acquired after admission/presentation to a health care setting.Patient death or serious injury associated with a fall while being cared for in a health care setting.Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy.Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a health care setting.Patient death or serious injury associated with unsafe administration of blood products.Patient death or serious injury 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 suicide, attempted suicide, or self-harm resulting in serious disability, while being cared for in a health care facility.Patient death or serious disability associated with patient elopement (disappearance).Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person.Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a health care setting.Patient death or serious injury associated with the use or function of a device in patient care, in which the device is used for functions other than as intended.Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the health care setting.Intraoperative or immediately postoperative/postprocedure death in an American Society of Anesthesiologists Class I patient.Unintended retention of a foreign object in a patient after surgery or other procedure.Wrong surgical or other invasive procedure performed on a patient.Surgery or other invasive procedure performed on the wrong patient.Surgery or other invasive procedure performed on the wrong body part.National Quality Forum List of Serious Reportable Events, 2016 Since the initial never event list was developed in 2002, it has been revised multiple times, and now consists of 29 'serious reportable events' grouped into 7 categories: Over time, the term's use has expanded to signify adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable. The term 'Never Event' was first introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF), in reference to particularly shocking medical errors-such as wrong-site surgery-that should never occur.

Joint commission sentinel event