Some adverse events do serious harm and are considered to be entirely preventable. Examples are surgery on the wrong site or wrong patient, an instrument or swab retained in a patient’s body, or the wrong dose of a medication.
In a seminal 2000 report, To Err Is Human, the Institute of Medicine recommended the creation of a national mandatory reporting system, using data collected by states, to track the frequency of adverse events that cause death or serious harm.
The National Quality Forum, a nonprofit private-public partnership, responded two years later by releasing a list of events that it termed “serious reportable events,” or “never events,” extremely rare medical errors that should never happen. That list was updated in 2011, with a total of 29 events focusing on surgical or invasive procedures, product or device events, patient protection events, care management events, environmental events, radiologic events, and potential criminal events.
As of 2008, 26 states had active, mandatory systems for hospitals to report serious adverse events to oversight authorities, although the types of reportable events and objectives of reporting programs varied. Notably, Minnesota publicly reports the number of “never events” by hospital. No nationwide reporting system has been established.