Never events

Never events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. They include incidents such as:

  • wrong site surgery
  • retained instrument post operation
  • wrong route administration of chemotherapy

Incidents are considered to be never events if:

  • there is evidence that the never event has occurred in the past and is a known source of risk (for example, through reports to the National Reporting and Learning System or other serious incident reporting system)
  • there is existing national guidance or safety recommendations, which if followed, would have prevented this type of never event from occurring (for example, for ‘Retained foreign object post procedure’ the referenced national guidance is related to the peri-operative counting and checking processes that would be expected to occur at the time of the procedure, including suturing after a vaginal birth)
  • occurrence of the never event can be easily identified, defined and measured on an ongoing basis.

You can find out more about never events and the 25 types of incidents that are considered to be never events in The never events list: 2013/14 update.

Surgical never events task force

NHS England commissioned a surgical never events taskforce to examine and clarify the reasons for the persistence of these patient safety incidents, and to produce a report making recommendations on how they can be eradicated. This report was published in February 2014, and NHS England has begun work on how the recommendations can be implemented.

Read more about the taskforce and view the report.

Never events data

As part of our commitment to be open and transparent about patient safety incident reporting, we have begun publishing data on never events in greater detail than ever before. The NHS in England is now one of the only healthcare systems in the world that is this open and transparent about patient safety incident reporting, particularly around never events. We are clear that we need to openly tackle these issues, not ignore them.