Four principles of “never events”

By Leah Binder

Phrase coined by The Leapfrog Group must become a reality

Lewis Blackman, an energetic and promising 15-year-old from South Carolina, underwent surgery to correct a common congenital deformity in his chest. The surgery was successful, but during his postoperative care, Lewis experienced an adverse reaction to an anti-inflammatory drug. Despite pleadings from his mother and obvious signs of deterioration, Lewis’ caregivers did not change his medication.

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