A term of art for an event which all knowledgeable professionals agree should never occur*.
*But does occur in surgery…at least 4000/year in the USA
Examples, never events (NEs) Sponge, gauze or surgical instruments left behind during surgery; performing the wrong procedure; performing a procedure on the wrong site; performing a procedure on the wrong patient.
Profile of NE surgeons 35% are 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 of ±$70 million/year.
Synonym Catastrophic surgical error
Reference Surgery, Dec 2012, M Makary, Johns Hopkins