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National Patient Safety Agency

Launch of Never Events policy for the NHS in England

Tuesday 3 March 2009


Today (3 March) the NPSA has officially launched a Never Events policy for the NHS in England. Never Events are serious patient safety incidents that should not occur if preventative measures have been put in place.


From April 2009, Primary Care Trusts will use the Never Events policy to help focus commissioning the safest services for their patients. Primary Care Trusts will be working with hospitals and other healthcare providers on using the Never Events policy locally, and the occurrence of Never Events will be monitored and publicly reported on an annual basis.


Eight core Never Events have been identified, including: wrong site surgery, inpatient suicide using non-collapsible rails and wrong route administration of chemotherapy.


At a seminar hosted by the NPSA and NHS Manchester today, Martin Fletcher, Chief Executive, NPSA, said: “The Never Events policy is a bold initiative designed to drive measurable improvements in patient safety.  Primary Care Trusts have a significant role in using commissioning as a lever for safer care. We’ve worked with the NHS to identify eight Never Events that are serious, largely preventable and have guidance available to prevent occurrence – healthcare providers need to ensure that this guidance is implemented.


He continued: “I am particularly appreciative of the input and support from NHS Manchester which is leading work on tackling Never Events and supporting us with today’s important seminar.”

NHS Manchester has been using the Never Events concept since late 2007, initially basing its work on approaches established in the USA to encourage local NHS services to identify and report patient safetyincidents, as well as sponsoring training for hospital staff.


This work has now resulted in each of the three main acute hospitals and mental health and social care trusts in the city developing innovative and ambitious programmes of work to prevent harm to patients from a number of common problems including pressure sores, blood clots, falls and drug errors.


Professor Rajan Madhok, Medical Director of NHS Manchester said “New drugs and treatments can save lives but equally can pose a risk of harm.  Some of this harm can be avoided by better systems of care including training and we are working with local services to ensure this happens.


“It is very encouraging that hospitals in the city have risen to the challenge and are ensuring patient safety is a top priority. We are all committed to working with the National Patient Safety Agency in taking forward the Never Events initiative and ensuring safer care for the people of Manchester. “

The first phase of implementation of the Never Events policy will be from 01 April 2009 to March 2010and will bebased on current commissioning arrangements and relationships, and the processes that underpin them.


View the Never Events Framework




Notes for editors:



Media enquiries to Amelia Lyons or Paul Cooney in the NPSA press office on 020 7927 9580/9351 or amelia.lyons@npsa.nhs.uk / paul.cooney@npsa.nhs.uk.



Never Events


A recommendation in High Quality Care for All proposed that there should be a way of identifying and monitoring ‘Never Events’.  These are events that are serious and largely preventable.  The National Patient Safety Agency has been asked by Lord Darzi to take this work forward with key stakeholders.  In particular from next year, Lord Darzi proposed that Primary Care Trusts will take this forward in their annual operating plan.


Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented by healthcare providers.


The eight Never Events identified are:


1.     Wrong site surgery

2.     Retained instrument post-operation

3.     Wrong route administration of chemotherapy

4.     Misplaced naso or orogastric tube not detected prior to use

5.     Inpatient suicide using non-collapsible rails

6.     Escape from within the secure perimeter of medium or high secure mental health services by patients who are transferred prisoners

7.     In-hospital maternal death from post-partum haemorrhage after elective caesarean section

8.     Intravenous administration of mis-selected concentrated potassium chloride.


The NPSA’s publication: Never Events – Framework 2009/10 has been produced by the NPSA and includes guidance to PCTs as commissioners on implementation of Never Events policy during 2009/10, described in The NHS England: The operating framework for 2009/10.




The National Patient Safety Agency is an Arms Length Body of the Department of Health. It encompasses three divisions; the National Research Ethics Service, the National Reporting and Learning Service and the National Clinical Assessment Service. Each has its own sphere of expertise to improve patient outcomes. The NPSA’s vision is to lead and contribute to improved, safe patient care by informing, supporting and influencing healthcare individuals and organisations.