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Never Events: What Are They and Why Do They Happen?

Posted on 11th December 2023 in Medical Negligence

Posted by

Simon Mansfield

Partner and Solicitor
Never Events: What Are They and Why Do They Happen?

Never events are serious, preventable patient safety incidents that should never happen in healthcare settings. 

Never Events are precisely that, events that should never happen. They are defined by the NHS as “adverse events that are serious, largely preventable, and of concern to both the public and health care providers for the purpose of public accountability”. 

The NHS has a list of 15 types of never events, which include wrong site surgery, wrong implant/prosthesis, retained foreign object post procedure, misidentification of patients, and overdose or underdose of insulin by a healthcare professional.

These events are considered to have strong and systemic barriers to prevent them from occurring, such as national guidance, safety recommendations, or standard operating procedures.

Therefore, Never Events, even if they are not life threatening, should act as red flags that an organisation is not following the correct procedures. They can therefore be a key indicator that there has been a failure to put in place or follow safety advice and guidelines.

What are the different types of Never Events?

NHS England records the Never Events under several categories.

·      Wrong site surgery

·      Retained foreign object post procedure

·      Wrong implant/prosthesis

·      Misplaced naso or oro gastro tubes and feed administered

·      Administration of medicine by the wrong route

·      Unintentional connection of a patient requiring oxygen to an air flowmeter

·      Overdose of insulin due to abbreviations or incorrect device

·      Transfusion or transplantation of ABO-incompatible blood components or organs

·      Falls from poorly restricted windows

·      Chest or neck entrapment in bed rails

·      Overdose of methotrexate for non-cancer treatment

·      Misselection of a strong potassium solution

·      Failure to install a functional collapsible shower or curtain rails

·      Mis-selection of high-strength midazolam during conscious

·      Scalding of patients

How many Never Events have happened?

Despite extensive safeguards, the provisional reports from the NHS England website, state there have been 179 never events reported as occurring between 1 April 2023 and 30 September 2023. The most common types of never events were wrong site surgery (91), retained foreign object post procedure (32), and wrong implant/prosthesis (19).

The impact of never events on patients and their families can be devastating, as they can result in serious harm, disability, or even death.

Prevention of Never Events

Therefore, it is vital that never events are reported, investigated, and learned from, to prevent them from happening again.

Never events are a serious issue that affect the quality and safety of healthcare delivery in the NHS. They are not inevitable, but rather the result of human error, system failure, or a combination of both.

How can Tozers help?

In our experience, patients often find it very difficult to come to terms with the fact that they have suffered injury as a result of a never event as they are aware that it could have so easily have been prevented.

If you or a family member have been affected by a Never Event, it is important to seek legal advice from one of our specialist Medical Negligence team.

Contact our legal experts

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