How to prevent "never events" for healthcare and EMS teams

"Never events" are serious, preventable incidents—often resulting in patient harm or death—that should not occur in healthcare settings. Originally defined by the National Quality Forum, these events include, but are not limited to, discharging patients unable to make decisions, deaths associated with restraints, patient elopement and medication errors. The ambulance industry is also experiencing such events, which can have catastrophic outcomes.

Prevention strategies

Identify known risks

• Review past incidents to understand recurring risks.
• Proactively seek out unknown risks by staying informed through journals, conferences and industry webinars.

Focus on likely scenarios

• Prioritize resources on events that are probable, rather than rare "black swan" occurrences.
  - Motor vehicle collisions
  - Patient elopement
  - Inability to access/locate a patient
  - Stretcher mishaps

Establish an emerging risk group

• Form a multidisciplinary team to monitor and address operational, clinical, financial and administrative risks.
• Include representatives from all departments to ensure comprehensive oversight.

Monitor technology and clinical changes

• Stay updated on new technologies and clinical practices.
• Assess risks associated with expanding service lines, new partnerships and regulatory changes.

Incident notification and documentation

• Implement clear procedures for reporting and documenting incidents.
• Ensure all staff understand notification protocols and documentation requirements for patient access and response scenarios.

Equipment and training

• Maintain and regularly inspect all equipment, such as stretchers and stair chairs.
• Provide ongoing training for staff on equipment use, troubleshooting and maintenance.
• Establish policies for equipment evaluation after incidents.

Credentialing and compliance

• Verify and monitor staff credentials and driver’s licenses regularly.
• Use available state and federal resources to ensure compliance.
• Employ systems to track credential expiration and restrict access for non-compliant staff.

Safe driving policies

• Enforce driver training and regular refreshers.
• Utilize telematics and driver feedback systems to monitor and improve driving behavior.
• Implement policies for seatbelt use and accident prevention.

Continuous improvement

Never event prevention is an ongoing process. Regularly review incidents, update policies and engage in industry learning to adapt to emerging risks. Utilize available checklists and self-assessment tools to identify and mitigate potential risks within your organization.

Source

Never events, Patient Safety Network (2024)
Never events: Things that happen, that shouldn't, Peter Dworsky (2025).