Learning from surgical Never Events

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Learning from 38 Never Events occurring in hospitals between April 2016 and March 2017.

NHS providers are encouraged to learn from mistakes and any organisation that reports a Never Event is expected to conduct its own investigation so it can learn from and take action on the underlying causes.

This report presents an analysis of the local investigation reports into 38 surgical Never Events from across England that occurred between April 2016 and March 2017 (the last full year with data available).

Although commissioned as part of our evaluation of the implementation of the national surgical safety standards for invasive procedures (NatSSIPs) — the learnings presented in the report will support providers to improve patient safety.

Learning from surgical Never Events PDF, 959.1 KB

Learning from 38 cases occurring in hospitals between April 2016 and March 2017.

The report follows on from similar reviews of nine cases in 2012 and 23 cases in 2014.

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