Extending the list of Never Events

Never Events are patient safety incidents that are preventable because there is guidance that explains what the care or treatment should be; there is guidance to explain how risks and harm can be prevented; and there has been adequate notice and support to put systems in place to prevent them from happening.1 The National Patient Safety Agency (NPSA) has defined a Never Event as ‘A serious, largely preventable patient safety incident that should not occur if the available preventative measures have been implemented by healthcare providers’. Despite many organisational and individual efforts to prevent such serious occurrences, they continue to occur in our healthcare system. Never Events were declared and defined in the NHS in England from April 2009 following Lord D’Arzi’s proposals in High Quality Care for All.2 This followed on from a previous Government report chaired by Sir Liam Donaldson, An Organisation with a Memory,3 which sought specifically to enable healthcare organisations and the NHS, in particular, to learn from mistakes made and to share learning among professionals to reduce harm to patients. Since that time, an enormous amount of work, research and development has been undertaken and patient safety itself has become a core feature of care delivery. When the Never Events policy was introduced, a number of core objectives were seen to be incorporated. The key to these objectives was to provide greater awareness among commissioners of care, to promote openness and transparency and to enable lessons to be learned from a defined set of events. During the first year, over 100 Never Events were reported to the NPSA, over half (57) of which were related to wrong site surgery. The second highest reported Never Event was related to misplaced naso or orogastric tubes. The events were reported from Trusts around England and occurred throughout the year. From a surgical perspective, it was purely coincidental that, in January 2009, the NPSA published the WHO Global Alliance for Patient Safety’s Safe Surgery Saves Lives surgical checklist and required every Trust in England and Wales to have implemented it into their operating theatres by February 2010. It was noted at the end of the year, that some of the Trusts reporting surgical Never Events had not yet implemented, or only partially implemented, the surgical safety checklist. A revised patient safety alert was released to the NHS following reports of the numerous misplacement of nasogastric tubes as the majority of the misplacements occurred out of hours mainly at night, or when X-rays were taken and checked at night, or when X-rays to check placement were misinterpreted. A recent publication from the Department of Health (DH) has extended the list of Never Events.4 The extended list covers many different fields of practice and extends the previous eight Never Events to 25.

Never Events for 2012/2013

 The new events added to the list include severe harm or death caused by misidentifying patients by failing to use standard wristband identification processes, severe harm or death due to transfusing the wrong type of blood, and severe scalding. Several relate to the incorrect use of drugs. The list was developed after consultation with the NHS, health professionals, the Royal Colleges, and the public.