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What are Never Events?

Never Events are serious incidents in healthcare. They’re called Never Events because they should never happen, due to guidance and safety recommendations in place. Incidents that can be classed as Never Events are officially designated by the NHS and are instances of medical negligence.

What is a Never Event?

The NHS defines Never Events as “Serious incidents that are wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers”.

Never Events are serious patient safety incidents which would have been avoided had the medical staff followed national guidance and safety recommendations. Some of the more common incidents include doctors operating on the wrong body parts, surgical instruments left behind in patients post-operation, and specific other medical negligence mistakes. All Never Events have the potential to cause death or serious harm, and as their name implies should never happen. As a result, the NHS has a framework for reporting and publishing data relating to the number and type of Never Events that occur nationally.

What are common examples of Never Events?

There are different types of Never Events, including the following examples:

  • Wrong site surgery
  • Wrong implant or prosthesis
  • Retained foreign object following procedure
  • Administration of medication by the wrong route
  • Incorrect dosage of medication
  • Falls from poorly restricted windows
  • Chest or neck entrapment in bed rails
  • Misplacement of naso-gastric or oro-gastric tubes
  • Scalding of patients
  • Unintentional connection of a patient requiring oxygen to an air flowmeter

Types of NHS Never Events

Never Events are serious, indefensible medical negligence incidents that should never occur, especially if all safety protocols are followed as they should be. The NHS uses the term ‘Never Events’ to refer to an unacceptable situation where a patient has suffered preventable harm or even death. Medical staff are required to report these incidents to ensure the NHS can continue to review safety procedures and work towards preventing any further incidents.

The NHS is currently consulting on the future of the Never Events framework.

How many Never Events happen a year?

In the most recent report NHS report covering 1st April 2022 - 31st March 2023, 410 serious incidents were reported on the StEIS system as being Never Events. Of these 410, 26 serious incidents did not appear to meet the definition of a Never Event, leaving 384 occurrences. These figures are high when you consider by definition, Never Events shouldn’t even happen once.

What is the NHS doing to learn from Never Events?

When a Never Event occurs, it is recorded and submitted so that the extent of the incident can be reviewed. All patients are entitled to safe medical care. The NHS say the reason for having a Never Events list is so any occurrence acts as a red flag that an organisation’s systems for implementing existing safety advice/alerts may not be robust enough.

The NHS published a revised Never Events policy and framework in January 2018 in which they stress that it “is not about apportioning blame when these incidents occur, but rather to learn from what happened”. Therefore, the revised framework removed the option for commissioners to impose financial sanctions when Never Events were reported, to avoid reinforcing the perception of a blame culture.