The causes of never events in hospitals

Howard Gitlow, Qun “amy” Zuo, Steven G. Ullmann, David Zambrana, Rafael E. Campo, David Lubarsky, David J. Birnbach

Research output: Contribution to journalArticlepeer-review

2 Scopus citations


Purpose – The purpose of this paper is to posit that it is possible to identify contributing factors for “never events,” preventable adverse events in the healthcare setting, and to develop “best practices” to prevent them. Design/methodology/approach – This paper focuses on three specific never events: patient falls, pressure ulcers, and hospital acquired pneumonia. A model is suggested to identify “gold standard best practice” protocols to be used to prevent these events. A literature review identifies two categories of factors: uncontrollable patient-related factors and controllable environmental related factors. The methodology is to use the Institute for Healthcare Improvement (IHI) Breakthrough Series Collaborative Model to develop best practice protocols for controllable environmental factors. Findings – Controllable environmental variables may be positively impacted by using Theory of Inventive Problem Solving (TRIZ), Value Stream Mapping, Kanban, 5S technique, Reduction of Complexity, Total Production Maintenance, Poke-Yoke, and Quick Change Overs. Controllable environmental variables may then be positively impacted by these methodologies and tools. Originality/value – The tools and methods indicated have been used individually in the healthcare sector, but this approach has never been used in an integrated manner. The concept is to work with patient safety organizations in order to reduce never events in healthcare; events that, to date, have significantly increased the costs of healthcare and reduced the quality of processes and outcomes in healthcare.

Original languageEnglish (US)
Pages (from-to)338-344
Number of pages7
JournalInternational Journal of Lean Six Sigma
Issue number3
StatePublished - Jan 1 2013
Externally publishedYes


  • Controllable environmental variables
  • Healthcare
  • Hospitals
  • Never events
  • Patient care
  • Patient safety
  • Risk management
  • Safety
  • Statistical process control
  • Uncontrollable patient variables

ASJC Scopus subject areas

  • Strategy and Management
  • Management Science and Operations Research
  • Industrial and Manufacturing Engineering


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