Discovering a Never Event: What to Disclose, When, to Whom, and Why

In 2008, the Centers for Medicare and Medicaid Services formally described "Never Events" as hospital-acquired conditions for which a hospital would not be reimbursed under the inpatient prospective payment system. While provisions have been created to prevent never events at hospitals, periodically, a never event is discovered incidentally. In the case of an incidentally discovered never event, the steps by which those discovered events are reported and disclosed are not clearly defined. In this discussion, we review methods by which one should discuss incidentally discovered never events and the steps to take in order to prevent future events from occurring.