never event

never event

A term of art for an event (for which there is universal professional agreement) that should never happen during surgery.
 
Examples
Sponge, gauze or surgical instrument left in the body after surgery; performing the wrong procedure, or on the wrong site or on the wrong patient.

Profile of Never Event surgeons
35% were age 40 to 49; 62% had more than one Never Event.

Consequences
Death in 7%, permanent injury in 33%, temporary injury in 60%; malpractice judgements.