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White Paper July 15, 2021

Preventing Never Events: Evidence based Nurse Staffing

Preventing 'Never Events': Evidence Based Nurse Staffing

Understanding "Never Events" is confusing at best. This white paper, authored by Bette Case Di Leonardi, PH.D., RN-BC, Marcia Faller, PH.D, RN, and Karen Siroky, MSN, RN-BC, describes adverse patient events as defined by various quality organizations, presents evidence to support the positive relationship between nurse staffing and the prevention of adverse patient outcomes and proposes two unique methods for calculating the cost and the value/payoff of investing in additional staff.


"Not in our unit. Not on our watch. Not to our patients.”AACN, 2009, p.15

Nurses sound this battle cry against preventable adverse events virtually every day, as part of their commitment to patient advocacy. Nurses implement evidence-based standards to protect patients from harm, but their efforts are effective only when they receive the support needed from sound staffing plans. These plans place nurses at the bedside in adequate numbers to deliver safe care and to permit nurses to obtain essential education for implementing standardized evidence-based practices. This white paper describes the adverse patient events currently defined by various quality organizations, presents evidence to support the positive relationship between nurse staffing and prevention of adverse patient outcomes, and proposes two distinct calculations that support the financial commitment for additional staff.

Quality Organizations Respond

Never Events arose among the array of safety initiatives spawned by the 1999 Institute of Medicine (IOM) report, To Err is Human. Kohn, et al, (1999) reported the alarming finding that the number of Americans who die each year from medical errors ranges from 44,000-98,000. Subsequent reports have validated little improvement in quality outcomes (Landrigan, et al, 2010).

Understanding Never Events is confusing at best. Confusion arises because numerous organizations have authored quality guidelines similar to Never Events, but not precisely the same. We first examine two organizations involved in setting quality care standards and compare them.

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