What does “Never event” mean?
Short answer
Never events are serious patient safety events that should never happen, like surgery on the wrong body part. The NQF list has 29 of them.
Also known as: serious reportable event, SRE
What it means
AHRQ PSNet says never events are clear (easy to spot and count), serious (death or major disability) and mostly preventable. Dr. Ken Kizer, then CEO of the National Quality Forum (NQF), coined the term in 2001.
The NQF list has 29 serious reportable events in seven groups:
- Surgical or invasive procedure
- Product or device
- Patient protection
- Care management
- Environmental
- Radiologic
- Potential criminal
Payment and reporting
In August 2007, CMS said it would stop paying extra costs from many preventable errors, including never events. PSNet says CMS has not paid for wrong-site surgery costs since February 2009. Many states and insurers did the same.
For surgery centers, wrong site, side, patient, procedure or implant is also a CMS quality measure (ASC-3) in the ASC Quality Reporting Program.
Mix-up: never events, sentinel events and adverse events overlap, but they are different lists. Never events come from NQF, sentinel events from the Joint Commission. An adverse event is any harm from care.
Frequently asked questions
Does 'never' mean these events never happen?
No. The name states a goal. These events are serious and mostly preventable. When they happen, they are reported and investigated.
How many events are on the NQF list?
AHRQ PSNet says the current list has 29 events in seven groups, from surgery and device events to criminal events.
Are never events reportable to a regulator?
It depends on your state and payers. CMS acts through payment rules, and many states copy them. Check your state and contracts.
Sources
- AHRQ PSNet: Never events (primer)
- CMS QualityNet: Ambulatory Surgical Center Quality Reporting Program
- Joint Commission: Sentinel Event Policy (SE chapter), Comprehensive Accreditation Manual, Update 1, July 2026
Reviewed against the sources above on Oct 5, 2026. Rules change: confirm current requirements with the issuing body or your counsel before relying on any summary.
Put the definition to work.
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