Never Events are defined by NHS England as serious, largely preventable patient safety incidents that should not occur if the healthcare providers have implemented existing national guidance or safety recommendations.
A Never Event requires full investigation under the Serious Incident framework, namely as each incident has the potential to cause serious harm or death.
The differentiation between a Never Event and a Serious Incident is that just one incident which is on the Never Event list will generate a ‘red flag’, indicating that the organisation’s systems for implementing the safety alerts and advice need improving.
The Never Events list includes the following incidents, categorised by the following headings:
Surgical
- Wrong Site Surgery
- This is surgery on the wrong patient or the wrong site.
- Wrong Site Implant or Prothesis
- This is the placement of an implant or prothesis which is different from that specified in the procedural plan, either before or during the procedure
- Retained Foreign Object Post Procedure
- ‘Foreign Object’ includes any item which is subject to a formal counting or checking process at the start of the procedure and before its completion
Medication
- Mis-Selection of Strong Potassium Solution
- This is where the patient is given a stronger dose of potassium solution than intended
- Administration of Medication by The Wrong Route
- This can be:
- Intravenous chemotherapy by the intrathecal route
- Oral/enteral medication or feed/flush by any parenteral route
- Intravenous administration of an epidural medication that was not intended to be administered by the intravenous route
- Overdose of Insulin Due to Abbreviations or Incorrect Device
- This can be:
- Where a patient is given a 10-fold or greater overdose of insulin because the words ‘unit’ or ‘international units’ are abbreviated, and such an overdose was given in a care setting with an electronic prescribing system
- A healthcare professional fails to use a specific insulin administration device, such as an insulin syringe or pen, to measure the insulin
- A healthcare professional withdraws insulin from an insulin pen or pen refill and then administers this using a syringe and needle.
- Overdose of Methotrexate for Non-Cancer Treatment
- This is where the patient is given more than intended weekly dose of methotrexate; an immunosuppressant used in cancer treatment.
- Mis-Selection of High Strength Midazolam During Conscious Sedation
- This is where the patient is given 5mg/mL or 2mg/mL instead of 1mg/mL of Midazolam.
Mental Health
- Failure To Install Functional Collapsible Shower or Curtain Rails
- This includes failure to install or the failure of these to collapse when an inpatient attempts or completes suicide
General
- Falls From Poorly Restricted Windows
- This includes windows which are in reach of patients, where a fitted restricted is damaged or disabled, or where patients can overcome this restrictor with their hands, available objects, or key.
- Chest Or Neck Entrapment in Bed Rails
- This is when the bedrail/ bedframe dimensions do not comply with the Medicines and Healthcare Products Regulatory Agency Guidance
- Transfusion Or Transplantation Of ABO
- This is when incompatible blood components or organs are used, however, the incompatible antibodies must be significant
- Misplaced Naso or Oro-Gastric Tube in Pleura or Respiratory Tract That Is Not Detected Before Starting a Feed, Flush or Medication Administration.
- Scalding Of Patients
- This is by water used only for washing/bathing
- Unintentional Connection of a Patient Requiring Oxygen To An Air Flowmeter
- Undetected Oesophageal Intubation has been temporarily suspended as a never event
There are several commonalities between different Never Event incidents, with most incidents occurring due to lack of communication, misplacement of paperwork and failure to double check with the patient or the checklist before operating.
Between 1 April 2021 and 30 November 2021, there were 278 incidents which met the definition of a Never Event in England. The Never Events which occurred the most were Wrong Site Surgery (117), with 36 wrong site blocks; Retained Foreign Object Post Procedure (66) with 23 vaginal swabs; Wrong Implant or Prothesis (35) with 10 knees; and Misplaced Naso- Or Oro-Gastric Tubes and Feed Administered (23), 11 of which were placement checks not described or clearly described.
Manchester University NHS Foundation Trust had the most never events between April and November 2021, with a grand total of nine; three of which were Wrong Site Surgeries.
Whilst they are rare, Never Events can have devastating consequences for those affected by them. If you think you have been a victim of a Never Event, please contact our Clinical Negligence Department who will be happy to discuss your concerns with you. Email info@tayloremmet.co.uk or call 0114 218 4000
