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What are Never Events?

Posted on 10th June 2021 in Medical Negligence

Posted by

Natasha Neary

Chartered Legal Executive
What are Never Events?

NHS Improvement defines Never Events as ‘patient safety incidents that are wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and have been implemented by healthcare providers’.

Although Never Events should not happen if all proper safety procedures are followed, unfortunately they do happen.  Provisional data indicates that 364 Never Events occurred in the NHS during the period 01 April 2020 to 31 March 2021. Never Events may highlight potential weaknesses in how an organisation manages fundamental safety processes.

Each type of Never Event has the potential to cause serious patient harm, or even death. For an incident to be categorised as a Never Event however, it does not need to be established that the specific incident resulted in serious harm or death.

 

Never Events List

The current Never Events list (2018) is as follows:

Surgical

  • Wrong site surgery
  • Wrong implant/prosthesis
  • Retained foreign object post procedure

 

Medication

  • Mis-selection of a strong potassium solution
  • Administration of medication by the wrong route
  • Overdose of insulin due to abbreviations or incorrect device
  • Overdose of methotrexate for non-cancer treatment
  • Mis-selection of high strength midazolam during conscious sedation

 

Mental health

  • Failure to install functional collapsible shower or curtain rails

 

General

  • Falls from poorly restricted windows
  • Chest or neck entrapment in bed rails
  • Transfusion or transplantation of ABO-incompatible blood components or organs
  • Misplaced naso- or oro-gastric tubes
  • Scalding of patients
  • Unintentional connection of a patient requiring oxygen to an air flowmeter
  • Undetected oesophageal intubation (temporarily suspended as a Never Event)

 

Never Event Data

The NHS is one of the only healthcare systems in the world that is open and transparent about patient safety incident reporting. This is particularly the case regarding Never Events.

On 13 May 2021, the NHS published provisional data regarding Never Events reported as occurring between 01 April 2020 and 31 March 2021. As above, the provisional data indicates that a total of 364 Never Events occurred during this period, whereas 472 Never Events were recorded for the previous period (1 April 2019 to 31 March 2020).

As the NHS was responding to the COVID-19 pandemic between 01 April 2020 and 31 March 2021, resulting in a major shift in service provision away from planned and elective surgery towards medical and intensive care, it would be inappropriate to compare the provisional Never Event data for the period 01 April 2020 to 31 March 2021 against data from previous years.

The table below provides a breakdown of the categories of Never Events reported between 01 April 2020 and 31 March 2021:

Never Events between 1/4/20 and 31/3/21 

Never Event Category

142

Wrong site surgery

80

Retained foreign object post procedure

30

Wrong implant/prosthesis

2

Mis selection of a strong potassium solution

24

Administration of medication by the wrong route

8

Overdose of insulin due to abbreviations or incorrect device

1

Mis selection of high strength midazolam during conscious sedation

4

Failure to install functional collapsible shower or curtain rails

28

Unintentional connection of a patient requiring oxygen to an air flowmeter

34

Misplaced naso- or orogastric tube and feed administered

8

Transfusion or transplantation of ABO incompatible blood components or organs

2

Scalding of patients

1

Chest or neck entrapment in bedrails

364

Total

 

The Never Event category with the greatest number of occurrences is wrong site surgery. Wrong site surgery is defined as ‘An invasive procedure performed on the wrong patient or at the wrong site (eg wrong knee, eye, limb, tooth). The incident is detected at any time after the start of the procedure.’

Stuart Bramley, co-head of our Medical Negligence team, recently reported on an error where a woman was given the wrong invasive procedure. Stuart’s article can be found here: NHS error sees woman given the wrong procedure | Tozers LLP

 

If you or your family have suffered because of medical negligence, we’ll help you to rebuild your life for the future. Contact us today and let us help you.

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