Never events in radiology and strategies to reduce preventable serious adverse events

The term never event in medicine was originally coined by Kenneth W. Kizer, MD, MPH, former chief executive officer of the National Quality Forum, to describe particularly shocking medical errors that should never occur, such as wrong-site surgery or death associated with introduction of a metallic object into the MRI area.With time, the National Quality Forum’s list of never events, or “serious reportable events,” has been expanded to include adverse events that are unambiguous, serious, and usually preventable. In this article, the never event framework has been used to describe (a) the errors that may occur in an imaging department that are serious and usually preventable with a review of the causative factors and (b) strategies to eliminate and reduce the adverse effects of these avoidable errors. These errors are often rooted in communication breakdowns and can only be eliminated with a true shift to a culture of open reporting and patient safety.