Pressure Ulcer Never Event

Certain types of medical events should never happen. Never events are a series of medical errors that are defined as “clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility.” Stage 3 and 4 pressure ulcers are listed as a never event by the Centers for Medicare and Medicaid Services.

Pressure ulcers, which are the fourth leading preventable medical error in the United States, are categorized as a never event because they are inexcusable outcomes in a health care setting. The development of pressure ulcers and skin breakdown is a direct reflection of care provided to patients by health care professionals. However, with constant caregiver dedication and the implementation of adequate skin and wound management, prevention of pressure ulcers is possible.