Never Events: reviewing the criteria

 Kate Woodhead RGN DMS discusses the findings of the HSIB’s review, including the complex factors that can lead to patient safety incidents.

Never Events are patient safety incidents which are considered to be wholly preventable where guidance or safety recommendations provide the framework for strong systemic protective barriers, which are implemented by providers of healthcare. Never Events are more common than one might assume, with 435 being recorded in England between April 2019 and February 2020 and, each year, they seem to remain stubbornly at the same level. Recent examples that have occurred in UK hospitals include the wrong hip replacement being put in during arthroplasty, surgical wire being left in a patient’s arm after heart surgery, a child being given an oral drug intravenously and the wrong fallopian tube being removed from a twenty-seven-year-old, resulting in infertility. 

A recently published report by the Healthcare Safety Investigation Branch  (HSIB)¹ has called into question a number of clinical incidents which attract the title of ‘Never Events’. The analysis into ten Never Events found barriers that were neither strong nor systemic, thus identifying that they do not fit the present criteria for Never Events, as they are not wholly preventable.