Event criteria and current list

The Government is clear that the current criteria for defining “never events” are the correct basis for expanding the list. To be a “never event”, an incident must fulfill the following criteria:

  • The incident has clear potential for or has caused severe harm/death
  • There is evidence of occurrence in the past (i.e. it is a known source of risk)
  • There is existing national guidance and/or national safety recommendations on how the event can be prevented and support for implementation
  • The event is largely preventable if the guidance is implemented
  • Occurrence can be easily defined, identified and continually measured

Their occurrence is a clear indicator of an organisation which has not put in place the right systems and processes to prevent the incidents from happening and thereby prevent harmful outcomes.  It is also an indicator of how safe the organisation is and the patient safety culture within that setting. The current “core eight” list of “never events” is:

  • Wrong site surgery
  • Retained instrument post-operation
  • Wrong route administration of chemotherapy
  • Misplaced naso or orogastric tube not detected prior to use
  • Inpatient suicide using non-collapsible rails
  • Escape from within the secure perimeter of medium or high secure mental health services by patients who are transferred prisoners. (not included in the contractual list of never events)
  • In-hospital maternal death from post-partum haemorrhage after elective caesarean section
  • Intravenous administration of mis-selected concentrated potassium chloride

The new list we are proposing contains or builds on the current core list and we are seeking comments and suggestions on all the proposed “never events” including those contained in the previous core list. It should be noted that “never events” and serious untoward incidents (SUIs) are not mutually exclusive. It is inevitable by their nature that all “never events” are SUIs, but not all SUIs are “never events”. The definition and reporting of SUIs was discussed in the recent National Framework for Reporting and Learning from Serious Incidents Requiring Investigation.

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