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Mitigating the risk of a ‘Never Event’

George Gallagher discusses why Never Events keep happening, why they matter and what we can all do about them to improve outcomes

Never Events are defined 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’.1 Despite their name, Never Events do happen and are surprisingly common. There were 314 serious incidents that met the definition of a Never Event between 1 April 2021 and 31 December 20212– that is more than one ‘entirely preventable’ event a day

Most obviously, they present a significant risk to patient safety and can lead to harm and even death, but there are a whole host of other consequences that impact patients and providers indirectly – including clinical negligence claims, delays in subsequent treatments, increased costs, and the effect on staff morale. 

Furthermore, the Never Events policy and framework – revised in January 2018, suggests Never Events may highlight potential weaknesses in how an organisation manages fundamental safety processes3 – in other words, they are often a symptom of a much larger issue. 

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Upcoming Events

Central Sterilising Club - Annual Scientific Meeting 2024

Crowne Plaza at Gerrard’s Cross
15th April 2024 – 16th April 2024

DECON UK 2024

National Conference Centre, Birmingham
17th April 2024

Infection Prevention & Control

National Conference Centre, Birmingham
23rd - 24th April 2024

Theatres & Decontamination Conference 2024

Coventry Building Society Arena
16th May 2024

The AfPP Roadshow - Birmingham

Millennium Point, Birmingham
18th May 2024

The AfPP Roadshow - Exeter

University of Exeter
22nd June 2024

Access the latest issue of Clinical Services Journal on your mobile device together with an archive of back issues.

Download the FREE Clinical Services Journal app from your device's App store

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