What is a Never Event in the NHS?

The NHS defines Never Events as ‘serious, largely preventable patient safety incidents that should not occur if relevant preventive measures have been put in place.’

As of 2018 The NHS currently records the following incidents as “never events”.

1. Wrong site surgery
2. Wrong implant/prosthesis
3. Retained foreign object post procedure
4. Mis-selection of a strong potassium solution
5. Administration of medication by the wrong route
6. Overdose of insulin due to abbreviations or incorrect device
7. Overdose of methotrexate for non cancer treatment
8. Mis-selection of high strength midazolam during conscious sedation
9. Failure to install functional collapsible shower or curtain rails
10. Falls from poorly restricted windows
11. Chest or neck entrapment in bed rails
12. Transfusion or transplantation of ABO incompatible blood components or organs
13. Misplaced naso or oro gastric tubes
14. Scalding of patients
15. Unintentional connection of a patient requiring oxygen to an air flowmeter

There were 445 never events recorded by the NHS in the period 01/04/2016 to 31/03/2017

And there were 393 never events for the period 01/04/2017 to 31/01/2018 (10 months).

If present trends continue (39 never events per month) this suggests that the total Never Events for the period of 01/04/2017 to 31/03/2018 will be 471, a figure slightly higher than last year.

This is after the Never Events list has been amended (as of January 2018) to temporarily suspend “undetected oesophageal intubation” from the list of never events until “further clarification”.

In America, the NQF (National Quality Forum) has defined a list of 27 Never Events which it expects all US hospitals to avoid.

They are as follows ;-

1. Artificial insemination with the wrong donor sperm or donor egg
2. Unintended retention of a foreign body in a patient after surgery or other procedure
3. Patient death or serious disability associated with patient elopement (disappearance)
4. Patient death or serious disability associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of administration)
5. Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO/HLA-incompatible blood or blood products
6.  Patient death or serious disability associated with an electric shock or elective cardioversion while being cared for in a healthcare facility
7. Patient death or serious disability associated with a fall while being cared for in a healthcare facility
8. Surgery performed on the wrong body part
9. Surgery performed on the wrong patient
10. Wrong surgical procedure performed on a patient
11. Intraoperative or immediately post-operative death in an ASA Class I patient
12. Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility
13. Patient death or serious disability associated with the use or function of a device in patient care, in which the device is used or functions other than as intended
14. Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility
15. Infant discharged to the wrong person
16. Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a healthcare facility
17. Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a health care facility
18. Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility
19. Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates
20. Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility
21. Patient death or serious disability due to spinal manipulative therapy
22. Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances
23. Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility
24. Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility
25. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider
26. Abduction of a patient of any age
27. Sexual assault on a patient within or on the grounds of the healthcare facility
28. Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of the healthcare facility

What probably jumps out at me from comparing the UK and USA lists is that stage 3 or 4 pressure sores are not considered to be a never event by the NHS. This is a scandal. In my opinion they clearly should be for all inpatients.

Another NHS never event should be “Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a health care facility”.

Two others which concern me are the failure of the NHS to record sexual assault on a patient within or on the grounds of the healthcare facility or Death or significant injury of a patient or staff member resulting from a physical assault, as never events. This is especially the case given the Jimmy Saville scandal at Stoke Mandeville.

I think that it is completely unacceptable that the NHS should be defending any of the claims set out above.

I could go on but I think you take my point that even with much lower thresholds in the NHS than the USA, the NHS is simply not doing enough to stop basic, completely avoidable errors from occurring.

At the same time, lawyers who bring claims against the NHS, are vilified by some parts of the media as “ambulance chasers” who are somehow undermining the world’s best healthcare system. These same commentators must be completely unaware of the lower standards (in comparison with the USA) that the NHS has set for itself.