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National Patient Safety Agency

Never Events - media statement

07 November 2008


A recommendation in High Quality Care for All proposed that there should be a way of identifying and monitoring ‘Never Events’ in England. These are events that are serious and largely preventable. The National Patient Safety Agency has been tasked to take this work forward with key stakeholders.


The purpose of developing a national set of Never Events is to strengthen the focus of commissioning on patient safety, in order to reduce serious incidents and improve transparency.  Never Events can be indicators of how effective an organisation is at implementing safer practices.  Monitoring Never Events as part of the contract between commissioners and providers forms part of the wider patient safety and quality agenda in the NHS.


The National Patient Safety Agency is working with the NHS to develop a national set of Never Events and guidelines for their use during 2009/10.  An initial list of Never Events (see below) has been developed with the opportunity for comment and feedback from key stakeholders. From next year, Lord Darzi proposed that Primary Care Trusts will choose priorities from this list in their annual operating plan. The initiative will launch in Spring 2009.


Primary Care Trusts will be able to use the national set of Never Events as part of their contract agreements with providers during 2009/10.  During this first year implementation will focus on promoting clear reporting and management systems for Never Events.  The experience from the first year will be used to work with the NHS and Department of Health to define linkages to payment regimes from 2010/11 onwards.


The NPSA will provide web resources including information and evidence to help providers strengthen systems to prevent Never Events.  The NPSA will publish an annual report of Never Events across the NHS and disseminate lessons learnt.



NPSA’s proposed list of Never Events:



1. Wrong site surgery

Definition: A surgical intervention performed on the wrong site (e.g. wrong knee,

wrong eye, wrong limb, wrong organ); the incident is detected after the

operation and the patient requires further surgery, on the correct site,

and/or may have complications following the wrong surgery.


Main care setting: Organisations that provide major, minor and/or day case surgery


2. Retained instrument post-operation

Definition: One or more instruments retained following an operative procedure.


Main care setting: Organisations that provide major, minor and/or day case surgery


3. Wrong route administration of chemotherapy

Definition: Intravenous or other chemotherapy (e.g. vincristine) that is correctly

prescribed but administered via the wrong route [usually into the epidural



Main care setting: Acute care


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

Definition: Naso or orogastric tube placed in the respiratory tract rather than the

intestinal tract and not detected prior to commencing feeding or other use.


Main care setting: All care settings


5. Inpatient suicide using non-collapsible rails or whilst on one-to-one observations

Definition: Suicide using curtain or shower rails or suicide whilst on one-to-one close

observations whilst an inpatient in an acute mental health setting.


Main care setting: Mental health


6. Absconding of transferred prisoners from medium or high secure mental health


Definition: A prisoner absconding from medium or high secure mental health services

where they have been placed for treatment on a Home Office restriction



Main care setting: Mental health


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


Definition: In-hospital death of a mother as a result of a haemorrhage following

elective Caesarean Section.


Main care setting: Acute care maternity services


8. IV administration of concentrated potassium chloride

Definition: Intravenous administration of concentrated potassium chloride.