Never Events are serious incidents that are entirely preventable because guidance or safety recommendations providing strong systemic protective barriers are available at a national level, and should have been implemented by all healthcare providers.
Revised Never Events policy and framework and Never Events list 2018
The revised Never Events policy and framework and updated Never Events list was published in January 2018, to become active upon initiation of the update to the 2017–2019 NHS Standard Contract on 1 February 2018.
This document was revised on 31 January 2018 as the 'undetected oesophageal intubation' category of Never Event has been temporarily suspended pending further clarification (see below). A further update was made in May 2019 to clarify that 'local anaesthetic blocks for dental procedures' is excluded from the 'wrong site surgery' category of Never Event (also see below).
This document highlights barriers identified in Patient Safety Alerts issued by the former National Patient Safety Agency that NHS organisations still need to routinely consider as part of clinical governance and ensure are embedded in clinical practice to prevent Never Events
Following a query raised in relation to the new ‘undetected oesophageal intubation’ category of Never Event, that category of Never Event has been temporarily suspended from the 2018 Never Events list while the query is resolved. Providers will not need to report this category of incident as a Never Events until the suspension has been lifted. Reporting of all other Never Events in the 2018 list should continue.
Following the revision of the Never Events framework and list, the definition of the Wrong Site Surgery Never Event states that this includes wrong site blocks (including blocks for pain relief). After extensive consultation with the professional organisations for dental surgery, it has been agreed that it should be clarified that wrong site infiltration of local anaesthetic for dental procedures (sometimes referred to as dental blocks) should not be reported as a Never Event as the systemic barriers are not strong enough to prevent these types of incidents from occurring. To clarify this, the Never Events list 2018 document was amended in May 2019 to add 'local anaesthetic blocks for dental procedures' to the list of exclusions under the 'wrong site surgery' category of Never Event.
Since the introduction of the revised Never Events list in February 2018, only one wrong site dental block has been reported.
Summary of January 2018 revisions
Revisions to the Never Events policy and framework have been made following a consultation with stakeholders at the end of 2016.
In response to the consultation and to further support learning from Never Events, the main changes to the revised policy and framework are:
- the removal of the option for commissioners to impose financial sanctions on trusts reporting Never Events
- to align the Never Events policy and framework with the Serious Incident framework, to achieve consistency across the two documents (a revised Serious Incident framework will be published later in 2018)
- revisions to the list of Never Events, including two additional types of Never Event.*
*Details of the rationale for amendments to the Never Events list can be found in appendix C of the Never Events list.
A summary of the consultation findings and our response can be found on the Never Events policy and framework review 2016/17.