If you’ve practiced for any amount of time, chance are, so have you.

According to the Agency for Healthcare Research and Quality, “never events” are 28 outcomes that should never occur in a health care setting.” Most of them result in patient death or serious injury.

After reading this recent Reader’s Digest article about physicians confessing their fatal mistakes, I couldn’t help but think of all the mistakes I’ve made (that I know of) as a nurse. I commend the doctors who shared their experiences. It couldn’t have been easy doing so; yet, it’s how we learn – lay people and professionals alike.

As I think, one event, in particular, always rises to the top of my thoughts. I try to suppress it; it never works.

The never event did result in serious injury leading to the patient’s death. A root cause analysis found numerous preventable system and environmental failures. Seven years later, it’s painful to think about let alone talk about, so please forgive my vagueness. That one event forever changed my view of nursing, hospital staffing, management, work environment, teamwork, hospital administration, my own nursing care – you name it. A paradigm shift occurred.

Never events should never happen, but they do. Not only do they change patients’ and families’ lives, they also change the lives of the healthcare professionals involved.