Systematic Refinement of a Delphi Consensus on Never Events in Emergency Medical Services – NEEMS-2-Study
Through a two-stage Delphi consensus process involving 42 experts from German-speaking countries, this study updated the 2014 NEEMS guidelines to identify four specific, preventable, and severe prehospital "Never Events," advocating for a subsequent shift in focus toward implementing mandatory "Always Actions" to enhance safety culture in emergency medical services.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
Imagine you are the captain of a rescue boat sailing through a stormy sea. The waves are high, the wind is howling, and you have to make split-second decisions to save lives. But here's the tricky part: you don't have a full medical team on board, you can't run lab tests, and you're working with a crew that might change every time you set sail. In this chaotic world of prehospital emergency care, doctors and paramedics face a unique challenge: how do you stop the absolute worst mistakes from happening when everything is so unpredictable?
To tackle this, safety experts use a concept called "Never Events." Think of these as the "unforgivable" mistakes in a game of chess—moves so obviously bad that if a player makes them, they lose immediately. In medicine, a Never Event isn't just a bad outcome; it's a disaster that is 100% preventable if the right safety rules are followed. It's like saying, "If you forget to check your parachute before jumping, that's a Never Event." The goal is to identify these specific, catastrophic errors so that medical teams can build "Always Actions"—unbreakable safety habits that must be done every single time, without exception. This paper dives into the emergency services world to figure out exactly which mistakes belong on this "Never" list.
The researchers behind this study, a team of experts from Germany, Austria, and Switzerland, decided to update a list they had made ten years prior. In 2014, they had created a catalog of potential "Never Events" for emergency medical services (EMS), but they realized the rules needed to be stricter. They wanted to make sure that only the most clearly recognizable and preventable disasters made the cut. To do this, they gathered 42 top experts—people who run emergency services, teach the next generation of medics, and study safety—and asked them to play a game of "Yes or No" on a list of 12 scary scenarios.
They used a method called the Delphi process, which is like a high-stakes, anonymous voting game. In the first round, the experts voted on whether each scenario was a "Never Event." To pass the first hurdle, an item needed a massive 90% agreement. If it didn't get that, it went to a second round where the bar was slightly lower at 80%. The experts could also leave comments to tweak the wording of the scenarios, but they couldn't add new ones. The goal was to find the tiny, crystal-clear list of mistakes that everyone agreed were absolutely unacceptable and totally avoidable.
The results were surprisingly strict. Out of the 12 scary scenarios they tested, only four made it onto the final "Never Event" list. The two biggest winners, both receiving a whopping 98% agreement, were:
- Death or severe harm due to unrecognized esophageal intubation: This happens when a breathing tube is accidentally put into the food pipe (esophagus) instead of the windpipe, and the team doesn't realize it until it's too late.
- Death or severe harm due to unrecognized hypoglycemia: This is when a patient has dangerously low blood sugar, and the team misses the signs, leading to a coma or death when a simple sugar fix could have saved them.
Two other items just barely squeaked through the second round with 86% agreement:
3. Omission of telephone-guided resuscitation: This is when a dispatcher realizes someone is having a cardiac arrest but fails to guide the caller on how to perform CPR, even though trained help is available.
4. Death or severe harm due to improper use of medical devices: This covers things like using broken ventilators, defibrillators, or oxygen tanks, or failing to follow hygiene rules with these tools.
The paper explicitly ruled out several other ideas that people might have thought were "Never Events." For example, they decided that medication errors did not quite make the cut, receiving only 78% agreement in the second round. While still dangerous, the experts felt they didn't meet the super-strict definition of being 100% preventable in every single chaotic EMS situation. They also rejected ideas like "death due to improperly secured equipment in the vehicle" (67% agreement) or "death due to missing personal protective equipment" (58% agreement). The reasoning was that while these are serious risks, they sometimes depend on factors outside the team's immediate control, like a sudden accident caused by another driver or the unpredictable nature of a mass-casualty event.
The authors are very clear that this isn't a magic wand that solves all safety problems. Instead, they suggest that by narrowing the list down to just these four "Never Events," the medical community can now focus on creating "Always Actions." These are the non-negotiable safety steps—like checking the breathing tube with a special monitor every time, or checking blood sugar on every confused patient—that must happen without fail. The study concludes that while the list is short, it is rock-solid. By agreeing on these four specific disasters, emergency services can build a stronger safety culture, ensuring that these preventable tragedies become truly impossible to ignore.
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