Defining healthcare never events to effect system change: A protocol for systematic review

This article outlines the protocol for a forthcoming systematic review that will identify events that are consistently or frequently labelled as never events, work that will allow organizations and researchers to direct resources to the events most amenable to reduction efforts.

Defining healthcare never events to effect system change: A protocol for systematic review

Abstract

A never event is the most egregious of patient safety incidents. It refers to events that should theoretically never happen, such as amputating the wrong limb.

The term “never event” is used around the world by a variety of medical and patient safety organizations and is synonymous with sentinel events and serious reportable events. Unfortunately, there is little consensus about which events, in particular, are never events. These differing lists hinder potential collaboration or large-scale analyses.

A recent systematic review by Hegarty et al. (2020) identified the need for a standardized definition for serious reportable events. The objective of our systematic review is to build on this by identifying those events that are consistently or frequently labelled as never events, which will allow organizations and researchers to direct resources to the events most amenable to reduction efforts.

Reference

Zaslow J, Fortier J, Bowman C, de Gorter R, Tsai E, Desai D, O’Neill P, Mimeault R, Garber G. Defining healthcare never events to effect system change: A protocol for systematic review. PLOS ONE [Internet]. 2022 Dec 15 [cited 2023 Jan 9];17(12)E0279113. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0279113