- Definition: Never events are serious, largely preventable incidents in healthcare that should never occur if proper safety protocols are followed.
Relevance : GS 2(Health )
- Origin: The term was introduced in 2002 by the National Quality Forum (NQF) in the United States and has since been adopted in countries like the U.S., U.K., and Canada.
- Examples: Operating on the wrong limb, insulin overdose, mismatched blood transfusion—these incidents can lead to severe consequences such as disability, death, or significant discomfort for patients.
- Variation in Lists: Different organizations maintain varying lists of never events—NHS (U.K.) lists 16 events, whereas the U.S. recognizes 29. This variation reflects the complexity of healthcare systems.
- Impact: Never events highlight systemic failures and the complexity of healthcare, involving multiple stakeholders and interactions between social, technical, human, organizational, economic, and regulatory components.
- Post-Event Protocol: Steps include offering an apology, formally reporting the incident, conducting a root cause analysis, and waiving any costs incurred due to the incident.
- Prevention Debate: While reducing the frequency of never events is possible, complete prevention remains aspirational due to the inherent complexities of healthcare systems.
- ALARP Principle: Adopting the As Low As Reasonably Practicable (ALARP) principle provides a balanced risk management approach to minimize these incidents.
- Challenges: Concentrating accountability on frontline healthcare workers fails to address systemic inefficiencies, infrastructure issues, and communication gaps that contribute to never events.
- Indian Context: In India, similar incidents are categorized under medical negligence rather than never events. Medical negligence involves failures to meet the expected standard of care, leading to harm.
