never event

noun3

1. •
   A bad event that should never occur.

   • The safety systems engineer examined records of never events across several industries, including health care, air traffic control, and nuclear power.
2. •
   A serious adverse medical event that should never occur and thus is, by strict definitions of preventability, always preventable, being unambiguous, clearly identifiable and measurable, and resulting in death or significant disability.

   • Wrong-site surgery is a never event because it is always preventable when adequate double checks and crosschecks are enforced.
3. •
   A particularly shocking preventable medical error that should never occur.

   • Kernicterus has been called a “never event,” identified on a list of “serious, egregious, preventable adverse events” by The Agency for Healthcare Research and Quality […] — 2003