How many Never Events happen in UK hospitals?


When it comes to patient care, medical ‘never events’ are exactly that: they should never happen. That is because these patient safety incidents are avoidable if healthcare providers ensure that safety recommendations and national guidance is followed.

Despite this, the number of never events seems to be increasing dramatically in the NHS, from 424 in 2016-17 to 621 between April 2018 and July 2019.

As ‘never events’ can result in irreversible and serious harm to patients and even death, it is very concerning to see this rise in numbers.

However, it is not because of a lack of focus in tackling never events. In fact, any organisation that reports a never event is expected to conduct its own investigation so that it can identify the cause and take action to avoid its repetition.

In addition, the Care Quality Commission and NHS Improvement have been carrying out a review of the issues that contribute to the occurrence of ‘never events' in NHS trusts.

So what is classed as a never event?

According to the NHS Improvement Never Events List 2018, these never events fall into several categories.

On the surgical side, they include wrong site surgery, wrong implant/prosthesis, and retention of a foreign object after an operation.

Never events involving drugs include selecting the wrong medication, failing to administer medication via the correct route and giving an overdose.

In addition, there are never events pertaining to mental health and general risks, including falls from poorly restricted windows, chest or neck entrapment in bed rails and transplantation of ABO-incompatible organs.

How to minimise never events

NHS Improvement has identified several areas that could help reduce the number of these unfortunate and unnecessary events.

These include minimising the number of interruptions and distractions that can affect a member of staff’s situational awareness and concentration at critical times.

Removing the need to transcribe information from one piece of paper to the other may also help reduce errors in copying data. In addition, using count policies to ensure all surgical instruments and other items used for operations are accounted for post-procedure should help avoid retention of these items in the patient’s body.

Whilst more work is needed to establish the best way for marking surgical sites to avoid wrong site surgery, the issue of implanting the wrong device on the right side can also be addressed in a number of ways. For example, manufacturers can clearly mark on both the device and its packaging what side the implant is designed for. In addition, systems can also be put in place to double check that the implant is of the correct size and designed for the relevant side of the body before the device is implanted.

By following these and other safety procedures and carefully reviewing never events as they happen, healthcare providers will be in a much better position to prevent incidents that are totally avoidable in the first place.

Mistakes happen and a loss of focus is a very human flaw, so a blame culture helps nobody. That said, as one surgeon pointed out, perhaps the best way for healthcare workers to stay focused is to keep thinking: “How would I feel if I had to live with the consequences of a never event?”