The concept of never events sounds appealing. Certain things should never happen.  There are some never events.  The surgeon should never remove the wrong leg or take out the wrong kidney.  They should never leave an instrument in your abdomen after surgery.  Patients should never receive another patient’s medications.

Many of the “never events” should rather result in reports of rates.  What is the rate of urinary tract infections from urinary catheters?  What is the DVT rate in hospitalized patients?  What is the readmission rate (by disease and adjusted for disease severity)?

These rates should function as targets.  They are fair rates, since on average better systems will help most of these.

So I do distinguish between safety rates and never events.