This "never event" (euphemistically called a "hospital acquired condition" by some in the healthcare industry) should never happen, which is why it's called a never event. Here's a link to the story from MSNBC:
Here's a link to a publication that lists certain serious reportable events in healthcare, i.e., never events, to wit: Serious Reportable Events in Healthcare – 2006 Update. Notice that the number 1 never event is surgery on the wrong body part.
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