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‘Never events’ reported to patient safety agency exceed 100 in one year


More than 100 “never events” - serious preventable safety errors - were reported to the National Patient Safety Agency last year, the organisation has said.

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The figures for April 2009 to 2010 were published in a report on Friday. On the same day, the Department of Health announced from next year there will be 14 additional never events added to the current list of eight.

Never events, an idea proposed by former health minister Lord Darzi, are defined as “very serious, largely preventable patient safety incidents that should not occur if the relevant preventative measures have been put in place”.

Reporting never events was not compulsory in 2009-10 but the NPSA said 111 were reported to its national reporting and learning system. Its report said they were “spread throughout England, occurred throughout the year and across different trusts”.

Fifty-seven - just over half - were related to wrong site surgery, the NPSA said. The second most reported category, with 42, was misplaced naso- or orogastric tubes.

The proposed new never events from April next year, which the government is consulting on, include death or serious disability associated with entrapment in bedrails; death or serious injury as a result of insulin overdose, or failure to prescribe or administer insulin when clinically indicated; and death or serious injury resulting from falls from unrestricted windows.


Readers' comments (2)

  • the 'never events I find most interesting report, one would hope that the WHO operative time out etc would eliminate these. What evidence is there that this was or not used at the events reported.

    From a personal point a F! insterted a Venflon last December and I told her she had hit a nreve, she took no notivce and pressed on with the result that a nerve was bisected and I have long term pain and anaesthesia. The consultant only recorded this in my notes at my insistance. that is very small incident which remains unreported officiallly.

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  • I am supprised iyt was only 110 reported never events. As with most voluntary reporting schemes the reports probably only represents the tip of the iceberg

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