Never events are defined as 'serious incidents that are wholly preventable because guidance or safety recommendations that provide strong systemic barriers are available at a national level and should have been implicated by all healthcare providers'.
The revised framework for never events from NHS Improvement took effect in February 2018 to coincide with the initiation of the updated 2017-2019 NHS Standard Contract. The never events framework will be aligned with a new serious incident framework, due to be published later this year.
The purpose of the revised policy is to make sure that learning takes place after something goes wrong, in order to prevent future harm. This, of course, requires a culture of openness where staff, patients and other stakeholders are free to speak up when a clinical incident occurs.
The MDU has previously argued that the term 'never events' is a misnomer and has commented on a past review of the never events policy and framework. Attempting to prioritise 'never events' over other patient safety incidents is misleading and potentially harmful, particularly as some of these other incidents may provide equally useful lessons. We are pleased to see the removal of the option to impose financial sanctions when a never event occurs, which will help to encourage a climate where staff are willing to report serious incidents.
List of events
There are 16 events on the list, which is a reduction from the policy prior to 2015/2016 where the list included 25 never events. The list includes all events which must be reported when they occur. Some of the previous never events have been revised and two new never events have been included.
These are:
- unintentional connection of a patient requiring oxygen to an air flowmeter
- undetected oesophageal intubation, although this has been temporarily suspended from the list pending further clarification.
MDU view
We believe there needs to be a more open acknowledgement that all clinical care involves risk. Things can and do go wrong, even where measures are put in place to prevent this.
When a clinical incident occurs that could, or has, put a patient at risk, it is important to find out as soon as possible what went wrong, why and to learn lessons from it so that similar events can be prevented in future. This should be the case regardless of the type of serious incident or whether it is categorised as a so-called never event.
This page was correct at publication on 18/05/2018. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.