Medical errors that should never happen

November 5, 2005

The National Quality Forum has identified these 27 mistakes -- dubbed ''never events" -- that are so serious and preventable that they should never occur in hospitals.

Surgery on the wrong body part

Surgery on the wrong patient

Wrong surgical procedure performed on a patient

Object left in patient after surgery

Death of a patient, who had been generally healthy, during or immediately after surgery for a localized problem

Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics

Patient death or serious disability associated with the misuse or malfunction of a device

Patient death or serious disability associated with intravascular air embolism

Infant discharged to the wrong person

Patient death or serious disability associated with patient disappearing for more than four hours

Patient suicide or attempted suicide resulting in serious disability

Patient death or serious disability associated with a medication error

Patient death or serious disability associated with transfusion of blood or blood products of the wrong type

Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy

Patient death or serious disability associated with the onset of hypoglycemia, a drop in blood sugar

Death or serious disability associated with failure to identify and treat hyperbilirubinemia, a blood abnormality, in newborns

Severe pressure ulcers acquired in the hospital

Patient death or serious disability due to spinal manipulative therapy

Patient death or serious disability associated with an electric shock

Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances

Patient death or serious disability associated with a burn incurred in the hospital

Patient death associated with a fall suffered in the hospital

Patient death or serious disability associated with the use of restraints or bedrails

Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider

Abduction of a patient

Sexual assault on a patient

Death or significant injury of a patient or staff member resulting from a physical assault in the hospital