The Bugaboo of the “Never Event”

This is one of the better articles I’ve read recently about the flawed concept of the “never event.”

The name is the first flaw – “never” is a poor word, implying that when such an event occurs (and it will) it must be due to failure on the part of the care system. “Never” is a pejorative term that ultimately restricts the development of introspective self-regulation at the system level, leading to guilt and shame within the hospital culture and the temptation to blame the individual at the sharp end.

The assumption of tangibility is the second flaw – as the authors point out, the numerator in the ratio changes as a function of how “never events” are defined. Since these events are constructs, cognitively pieced together after the fact, the boundaries separated these events from all other adverse events are fuzzy and shifting. But the denominator is also a problem – how exactly is an opportunity for the “never event” operationalized? Regardless of what we do to event counts, we can also “cook the books” by expanding the definition of what an “opportunity” is, inflating the denominator without a requisite change in the numerator. Our numbers look better, but the events are still there.

The authors state that, in their systems, they look beyond the singular concept of the “never event” and seek to understand adverse events as a whole, regardless of their artificial designation. By doing so, they show empirically-validated improvements in adverse events without arguing whether something should never happen.

If we truly want to advance safety, we must abandon a priori classifications of errors based on whether we feel that they should (or should not) occur frequently. This limits our problem solving ability and ultimately constrains our creativity as a discipline.