Most Frequently Occurring Never Events (1995-2025 )

Author: Sharon Banks, RN, MN, LNC

Website: www.claritylegalnurseconsultingpllc.com

Never events, often referred to as sentinel events, are serious and largely preventable patient safety incidents that should not occur if appropriate preventive measures are implemented. These events are tracked across various healthcare settings, including hospitals, nursing homes, and long-term care facilities.

The occurrence of never events varies by category and facility type. Common examples include surgical errors (such as wrong-site or wrong-patient surgery), care management mistakes (like medication errors and patient falls), patient protection failures (for instance, infant discharge errors and restraint-related injuries), and environmental incidents (such as electric shocks or burns).

Data from organizations such as the Joint Commission and the Agency for Healthcare Research and Quality (AHRQ) highlight that thousands of never events are reported annually in the United States. These incidents have significant consequences, with legislative findings indicating that a substantial proportion result in patient fatalities. Compliance monitoring and medical malpractice litigation have contributed to the reduction of never events over the past decades, encouraging ongoing patient safety initiatives and changes in healthcare practices.

Never events, also known as sentinel events, are serious, largely preventable patient safety incidents that should not occur if proper preventive measures are in place. The frequency and type of these events vary by category and healthcare facility. Over the past three decades, specific patterns have emerged across different healthcare settings.

 

Most Common Never Events by Category

Surgical Events

Surgical never events include errors such as wrong-site surgery, wrong-patient surgery, and retained foreign objects after surgery. These types of mistakes are among the most prevalent never events, especially in acute care hospitals where surgical procedures are performed regularly.

Care Management Events

Care management never events include medication errors leading to serious injury or death, incompatible blood transfusions, and patient falls that result in significant injury or fatality. Medication errors and patient falls are widespread in both hospitals and long-term care facilities.

Patient Protection Events

This category includes events such as discharging an infant to the wrong person and injuries or deaths arising from the use of restraints or bedrails. These incidents are most frequently observed in pediatric and long-term care facilities.

Environmental Events

Environmental incidents, including electric shocks, burns, or falls resulting in significant injury or death, are documented in various healthcare settings, with a higher rate of occurrence in hospitals.

Administrative Never Events

Recently recognized by the Centers for Medicare and Medicaid Services (CMS), administrative never events include aggressive debt-collection practices, noncompliance with price-transparency requirements, and inequitable care policies. Although these events may cause subtle harm, their impact is significant and increasingly noted in hospital environments.

 

Most Common Never Events by Specific Event

1. Unintended Retention of a Foreign Object: The most commonly reported sentinel event involves items such as sponges, gauze, or surgical instruments left inside the patient.
2. Wrong Site/Wrong Patient/Wrong Surgery: Consistently reported, these events include performing surgery on the wrong body part or patient, or conducting the wrong procedure.
3. Patient Falls: Falls resulting in injury or death are a leading type of preventable never event.
4. Pressure Ulcers: The development of advanced pressure injuries (Stage 3, 4, or unstageable) on the skin over bony prominences, such as the buttocks, heels, and elbows.
5. Misplaced Tubes: Incidents where nasogastric or orogastric tubes are incorrectly placed, such as inserting a stomach tube through the mouth instead of the nose.

Never Events by Healthcare Facility Type

Acute Care Hospitals

In acute care hospitals, surgical events and care management incidents (such as medication errors and falls) are most frequent. Hospitals are also cited for product- and device-related events and radiologic events, including injuries associated with Magnetic Resonance Imaging (MRI) procedures.

Assisted Living Facilities and Adult Day Care Centers

These facilities report a high incidence of patient protection and care management events, including falls and medication errors. Research indicates that administrative practices in these settings are closely linked to never events, contributing to CMS’s decision to include administrative categories as never events in 2025.

Nursing Homes

Historically, over 70% of nursing homes have been cited for violations related to inadequate staffing and care, contributing to the occurrence of never events. Elder abuse and administrative failures are significant issues in these settings. Statistical data indicate that never events continue to occur thousands of times annually in the United States, with more than 114 distinct events identified across long-term care settings as of 2021. Legislative findings from 1995 to 2015 show that more than 70% of never events reported to the Joint Commission were fatal, highlighting their severity.

Reporting and Impact

CMS requires states to report never events to registries that track event type and facility category. These reporting requirements support ongoing patient safety initiatives aimed at reducing the incidence of never events. For more detailed statistics and trends, the Agency for Healthcare Research and Quality (AHRQ) and the Private Healthcare Information Network (PHIN) provide data on never events by provider and event type. However, specific frequency rankings, by category and facility type, are not available in the PHIN data.

State healthcare facility compliance monitoring and medical malpractice litigation have played a crucial role in reducing the occurrence of never events and encouraging the adoption of updated patient safety initiatives across healthcare settings.

Key Data Trends and References (1995-2025)

• The Joint Commission, Sentinel Event Database
• AHRQ (PSNET): Defines and tracks Never and Serious Reportable Events
• Surgical Never Events in the United States (2013 Study)
• Centers for Medicare and Medicaid Services (CMS): Defines never events in the context of “no pay for errors” policies

Most Frequently Occurring Never Events (1995-2025 )

Overview of Never Events

Never events, also referred to as sentinel events, are serious and largely preventable patient safety incidents that should not occur if appropriate preventive measures are implemented. These incidents are monitored across a range of healthcare environments, including hospitals, nursing homes, and long-term care facilities.

Never events are categorized by type and facility, with notable examples including surgical mistakes (such as wrong-site or wrong-patient surgery), errors in care management (like medication errors and patient falls), failures in patient protection (such as infant discharge errors and restraint-related injuries), and environmental incidents (for instance, electric shocks or burns).

Annual data from organizations such as the Joint Commission and the Agency for Healthcare Research and Quality (AHRQ) indicate that thousands of never events are reported each year in the United States. These incidents can have substantial consequences, with legislative findings indicating that various never events result in patient fatalities. Compliance monitoring and medical malpractice litigation have helped reduce the occurrence of never events, supporting ongoing patient safety initiatives and changes in healthcare practices.

The frequency and nature of never events vary by category and healthcare facility. Over the past three decades, specific patterns have emerged, highlighting the areas where these events are most common.

Most Common Never Events by Category

Surgical Events

Surgical never events include errors such as wrong-site surgery, wrong-patient surgery, and retention of foreign objects after surgery. These are among the most frequently reported never events, particularly in acute care hospitals where surgical procedures are performed regularly.

Care Management Events

Care management never events encompass medication errors that result in serious injury or death, incompatible blood transfusions, and patient falls causing significant injury or fatality. Such events are widespread in hospitals and in long-term care facilities.

Patient Protection Events

Patient protection never events involve incidents such as discharging an infant from the hospital to treatment(s) provided to the wrong person, resulting in harm, injuries, and deaths associated with restraints or bedrails. These are most often encountered in pediatric and long-term care settings.

Environmental Events

Environmental never events include electric shocks, burns, and falls resulting in serious injury or death. These incidents are reported in various healthcare settings, with higher rates in hospitals.

Administrative Never Events

Administrative never events, recently recognized by the Centers for Medicare and Medicaid Services (CMS), consist of aggressive debt-collection practices, failure to comply with price-transparency regulations, and inequitable care policies. While these events may cause less obvious harm, their impact is significant and increasingly observed in hospital settings.

 

Most Common Never Events by Specific Event

1. Unintended Retention of a Foreign Object: The most frequently reported sentinel event involves items like sponges, gauze, or surgical instruments inadvertently left inside a patient after surgery.
2. Wrong Site/Wrong Patient/Wrong Surgery: These events include surgeries performed on the wrong body part or patient, or conducting the incorrect procedure.
3. Patient Falls: Falls that result in injury or death are among the most common and preventable never events.
4. Pressure Ulcers: The appearance of advanced pressure injuries (Stage 3, 4, or unstageable) on skin over bony areas, such as the buttocks, heels, and elbows.
5. Misplaced Tubes: Incidents where nasogastric or orogastric tubes are incorrectly placed, such as inserting a stomach tube through the mouth instead of the nose.

 

Never Events by Healthcare Facility Type

Acute Care Hospitals

In acute care hospitals, surgical never events and care management incidents, such as medication errors and falls, are most frequently reported. Hospitals also encounter product- and device-related events and radiologic incidents, including injuries associated with MRI procedures.

Assisted Living Facilities and Adult Day Care Centers

These facilities report a high occurrence of patient protection and care management events, including falls and medication errors. Research shows that administrative practices in these settings are closely linked to never events, which led CMS to include administrative categories as never events beginning in 2025.

Nursing Homes

Over 70% of nursing homes have historically been cited for violations related to inadequate staffing and care, which contribute to the occurrence of never events. Elder abuse and administrative failures are notable concerns in these environments. Statistical data indicate that never events occur thousands of times annually in the United States, with more than 114 distinct events identified across long-term care settings as of 2021. Legislative findings from 1995 to 2015 reveal that more than 70% of never events reported to the Joint Commission were fatal, underscoring their severity.

Reporting and Impact

CMS mandates state-level reporting of never events to registries that track event type and facility category. These requirements support ongoing patient safety initiatives aimed at reducing the occurrence of never events. For additional statistics and trends, the Agency for Healthcare Research and Quality (AHRQ) and the Private Healthcare Information Network (PHIN) provide data on never events by provider and event type; however, PHIN does not provide specific frequency rankings by category or facility.

Compliance monitoring and state-level medical malpractice litigation have been instrumental in reducing the frequency of never events and in encouraging the adoption of updated patient safety initiatives across healthcare settings.

Key Data Trends and References (1995-2025)

• The Joint Commission, Sentinel Event Database
• AHRQ (PSNET): Defines and tracks Never and Serious Reportable Events
• Surgical Never Events in the United States (2013 Study)
• Centers for Medicare and Medicaid Services (CMS): Defines never events in the context of “no pay for errors” policies