Never Events

As of 1 April 2016, Patient Safety is now part of NHS Improvement.

Find out more about how NHS Improvement works.

Never Events are serious incidents that are wholly preventable as 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.

Each Never Event type has the potential to cause serious patient harm or death. However, serious harm or death is not required to have happened as a result of a specific incident occurrence for that incident to be categorised as a Never Event.

Never Events include incidents such as:

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

Revised Never Events Policy and Framework

A revised Never Events Policy and Framework was published on 27 March 2015, this includes changes to the definition of what a Never Event is and adjustments to the types of incident that are included on the Never Events list, reducing the list from 25 to 14 incident types.

The Never Events Policy and Framework should be read in conjunction with the Serious Incident Framework.

The March 2015 Revised Never Events Policy and Framework supersedes the previously published The never events list: 2013/14 update and the Department of Health’s The Never Events Policy Framework: an update to the never events policy.

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 their occurrence can be minimised. 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.

National Safety Standards for Invasive Procedures (NatSSIPs)

One of the recommendations of the Surgical Never Events Taskforce report was to develop a set of high-level national standards of operating department practice that will support all providers of NHS-funded care to develop and maintain their own more detailed, standardised local procedures.

The National Safety Standards for Invasive Procedures (NatSSIPs) were published in September 2015 to support NHS organisations in providing safer care and to reduce the number of patient safety incidents related to invasive procedures in which surgical Never Events can occur. The NatSSIPs cover all clinical areas in which invasive procedures are undertaken.

Read more about NatSSIPs and view the standards document.

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 few 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 openly and not ignore them.