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Clinical Case Review: A Double “Never Event”

  • Writer: Jeanette Zocco
    Jeanette Zocco
  • Sep 6
  • 3 min read
Patient in the ICU

Patient safety is the foundation of quality healthcare. Yet, even in highly monitored environments like the ICU, serious errors can happen—sometimes more than one in a single event. This clinical case review presents a real example of a double “never event” that affected a patient. It discusses what went wrong and why it happened. 


A patient in the ICU was ordered a procedure to aspirate fluid from his left ankle. The surgical intern and second-year resident entered the patient’s room and acquired consent over the phone from the patient’s wife. A time-out was conducted with the bedside nurse, who questioned why the procedure was being done, as the patient had wounds on both feet and osteomyelitis in his left foot. At this point, one of the residents double checked the electronic medical record to ensure they had the correct patient, reporting this to the nurse and the other resident.

Despite the nurse’s continued concern, they moved forward. The procedure was conducted on the patient’s right ankle and shortly after a third resident entered the room, notifying the other residents that this was the wrong patient. The procedure was immediately discontinued, and the patient and family were informed that an error had occurred. There were no further complications resulting from this procedure (Bellini & Salcedo, 2024).


How did this happen?

✅ Room proximity – The two patients were in neighboring rooms. 

✅ Patient unable to provide informed consent 

✅ Residents unfamiliar with the proper time-out protocol 

✅ Flawed time-out process – Key verification steps were missed:

  • Correct patient

  • Correct procedure

  • Correct site

  • Full team agreement-the RN continued to voice concerns (Bellini & Salcedo, 2024)


Key Considerations

✔ All team members must be “in the moment”- paying attention during the time-out instead of multitasking during this time

✔ A checklist must be used to ensure no steps in the process are missed 


Never Events

“Never event” is a phrase created in 2001 by Kenneth Kizer, CEO of the National Quality Forum (NQF), that refers to blatant medical errors, such as the retention of foreign objects after surgical procedures. The original list of never events has evolved into what is now known as the  Serious Reportable Event (SRE) list. It is used by many states for mandatory reporting, to identify system problems and drive improvement efforts in patient safety (National Quality Forum, 2024). 

Examples of never events: 

✅Unintentionally retained foreign objects after surgical or invasive procedures 

✅Death or serious harm due to patient elopement

✅Medication errors causing death or serious harm

✅Maternal or neonatal death or injury associated with labor or delivery in low-risk  pregnancies (UC Davis PSNet Editorial Team, 2024)


Knowledge Check

1. What type of event would this qualify as?

A) Near miss

B) Never event 

C) Sentinel event

D) B & C


Answer: D 

Explanation: This case qualifies as a never event, defined as an “adverse event that is distinct, serious, and usually preventable’” (Bellini & Salcedo, 2024, para 4). It includes errors involving the wrong site or wrong patient. In this case there were two never events, the wrong patient and the wrong site. 


It also qualifies as a Joint Commission sentinel event because it was an event involving a wrong patient and wrong site procedure, regardless of the harm outcome (The Joint Commission, 2025). Wrong patient, wrong site, or wrong procedure, surgical or invasive would all meet the definition. It would not qualify as a near miss because the event reached the patient.


2. Which risk reduction strategies, when implemented properly, would have ensured the correct patient, procedure and site?

A) Timeout

B) Patient Identification

C) Structured handoff 

D) All of the above 


Answer: D) all of the above. (structured handoff to the covering resident)


💡 Interested in more safety content and strategies? Check out my book: 📘 Obstetric and Neonatal Quality and Safety (C-ONQS) Study Guide: A Practical Resource for Perinatal Nurses Available on Amazon: Amazon_obneonatalstudyguide


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References:


Bellini, A., & Salcedo, E.S. (2023, September 27). A Double “Never Event”: Wrong Patient and Wrong Side. PSNet Patient Safety Network. Retrieved on 9/6/25 from https://psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side


National Quality Forum. (2024, April 4). NQF to Update and Harmonize Serious Adverse Event Reporting Criteria Essential to Protect Patients From Preventable Harm. Retrieved on 9/6/25 from https://www.qualityforum.org/en-us/news/nqf_to_update_and_harmonize_serious_adverse_event_reporting_criteria_essential_to_protect_patients



UC Davis PSNet Editorial Team (September 15, 2024). Never Events. Agency for Healthcare Research and Quality PSNet Patient Safety Network. Retrieved from https://psnet.ahrq.gov/primer/never-events


Copyright by Jeanette Zocco MSN RNC-OB, C-EFM, C-ONQS


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