Kuy SR, Gupta R, Roy C, et al. - The US Center for Medicare and Medicaid Services (CMS) adopted the term never event, which was first introduced in 2001 by Ken Kizer and the National Quality Forum, to define preventable hospital-acquired conditions, such as catheter-associated urinary tract infections (CAUTI). Researchers sought to describe the incidence of CAUTI in a large academic medical center and to establish that CAUTI cannot truly be a never event even with prevention guideline adherence. Using appropriate preventive strategies, 60% to 75% of CAUTIs could be avoided. The US Centers for Disease Control and Prevention introduced guidelines in 2005 through the Surgical Care Improvement Project in attempt to limit CAUTIs. In 2008, reimbursement was stopped by CMS to hospitals for treatment of CAUTI as part of what it now identified as the Hospital-Acquired Condition Reduction Program, with the goal of making CAUTIs a never event.However, CAUTIs continue to occur and cause significant morbidity for patients despite these guidelines and payment penalties.