Never Event
en.wikipedia.org
en.wikipedia.org
"Wrong site surgery", "retained instrument post-operation", "infant discharged to wrong person", sure, absolutely agree processes can and should be such that this can literally never happen.
On the other hand, "Intraoperative or immediately postoperative death in an ASA Class I patient" seems like one which is ultimately in the lap of the gods: we certainly can and should make those odds really good (maybe much better than they currently are) by improving processes and ranking surgeons by their error statistics and so on. But sometimes people do just die, and the best surgeon could make a one-in-one-thousand slip of the hand (because human bodies just aren't built for such perfect fine motor control). And "serious injury or death associated with a fall": again, I'm not sure there are processes even in principle which could prevent a determined patient from injuring themselves by taking a fall, short of tying them to the bed or otherwise disabling them. There's a solid chance I, a basically-healthy patient in a ward, could be socially engineered into helping the miserable elderly patient next door to get out of bed for a short walk; so now your processes need to be robust to having young healthy people actively trying to break them! This problem seems not like the others.
When our daughter was born, we didn't let her out of our sight until my wife left the hospital. Sure, they have these bracelets that prevent switching babies (which happened to my wife's grandmother in 1960ies Switzerland), but our worst nightmare was that someone simply took and walked out with her.
Sometimes it felt like it was overdone, and sometimes it felt like the most important thing in the world.
edit: scrolled further and saw that in the UK we have a different list, so I guess this would count as "Wrong site surgery"
It is the complete opposite of sensible risk management, and serves only the politicians who find it difficult to publicly admit the fact that some level of risk must be accepted, which isn’t something I think the public should encourage.
It also removes any level of accountability for actually having to achieve a goal, because no achievable goal was ever defined to begin with.
Of course, if everyone agrees that a goal isn't achievable (or it's not worth the effort to achieve it), then it will never be achieved...
However, certain commercial operations like air taxis and flight instruction fall under the much less restrictive part 61 and there are tons of incidents all the time.
Original poster meant to say part 141 has been very good at making airline safely profoundly good lately.
> As of 2019, 11 states have mandated reporting for never events, and an additional 16 states have mandated reporting for serious adverse events including never events.