Mitigating the risk of a ‘Never Event’

Never Events are defined as ‘Serious Incidents that are wholly preventable because 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’.¹ Despite their name, Never Events do happen and are surprisingly common. There were 314 serious incidents that met the definition of a Never Event between 1 April 2021 and 31 December 2021²– that is more than one ‘entirely preventable’ event a day

Most obviously, they present a significant risk to patient safety and can lead to harm and even death, but there are a whole host of other consequences that impact patients and providers indirectly – including clinical negligence claims, delays in subsequent treatments, increased costs, and the effect on staff morale. 

Furthermore, the Never Events policy and framework – revised in January 2018, suggests Never Events may highlight potential weaknesses in how an organisation manages fundamental safety processes³ – in other words, they are often a symptom of a much larger issue.