never event n. a (serious or life-endangering) medical error. Editorial Note: So-called because such occurrences should never happen. (source: Double-Tongued Dictionary)
Further reading
She sells seashells by the seashore. Who is the she in this tongue twister? Some claim it’s the young Mary Anning, who went on to become a famous 19th-century British paleontologist. Dubious perhaps, but the story of her rise from seaside...
Books were rare treasures in the Middle Ages, painstakingly copied out by hand. So how to protect them from theft? Scribes sometimes added a curse to the first page of those books that was supposed to keep thieves away — and some were as vicious as...
Considering the legislation being enacted that refers to this list, they do a good job of not making it available online.
Bob – see following link for the NWF list:
http://www.qualityforum.org/pdf/news/prSeriousReportableEvents10-15-06.pdf
I submitted the following to the CDC on July 9th. ” I’m looking to obtain information regarding the reuse of in-line galvanic oxygen sensors. Sensors placed on the inspiratory limb of ventilators and anesthesia breathing curcuits. Manufactures state: CAUTION: DO NOT USE ETHYLENE OXIDE STERILIZATION. DO NOT IMMERSE THE SENSOR IN ANY CLEANING SOLUTION, AUTOCLAVE OR EXPOSE THE SENSOR TO HIGH TEMPERATURES. That being the case, how are care givers completely assured they are not contaminated between patients.
If this information is not available through your department, could you direct me to someone who may assist”.
Their reply on July 10th.
To: DHQP Inquiry (NCID/DHQP) (CTR)
Cc: Aydlotte, Susan (CDC/CCHIS/NCHM (CTR)
Below, please find an inquiry from a Medical Equipment Development Company related to patient contamination / infection from the reuse of galvanic oxygen sensors. This inquiry is being escalated because of the technical nature of the question.
Please advise immediately if your group will provide the answer to this inquiry of if the inquiry should be referred elsewhere, for example to a state / local health department, other CDC program, or other Federal agency. Specific guidance on a referral and contact information would be appdreciated.
Programs answering the inquiry should do so by 17 July 2008. If there is a delay, please let us know when to expect the answer so that we can comunicate that information to the inquirer.
Question about this inquiry can be directed to CDC-INFO Correspondence Team by replying to this email or by phone at 601.718.1281. Please reference the service record below and include the Thread Line in your response.
If you contact the inquirer directly, please provide the answer to cdcinfo@cdc.gov so it can be added to the database and limit repeat questions. You may also want to consider adding general information to you website to reduce inquiries.
Thank you for your assistance.
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Comments to my question and the response from the CDC would be greatly appreiciated.