What is a ‘Never Event’? These are serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations. The latest provisional figures published by NHS England confirm that from 1st April 2021 – 31st March 2022 there were 407 ‘Never Events’ reported which is an increase from 364 reported in the same period in the previous year.

 

The figures reported there were 98 cases of a foreign object being left inside a patient after a procedure. Some of these objects included a bolt from surgical forceps, part of a drill-bit, Catheter used as part of a surgical procedure, part of a pair of wire cutters and a scalpel blade. In addition, vaginal swabs were left in patients on 32 occasions and surgical swabs on 21 occasions.

 

Shockingly, 171 patients were operated on at the wrong site on their body, and one lady unfortunately had her ovaries removed when the surgical plan was to conserve them. The data also shows that 6 patients had injections into the wrong eye and 3 patients had angioplasties performed on the wrong side. In addition, during the last year, 47 patients received the wrong implant/prosthesis, which included patients receiving the wrong hip implants on 12 occasions and there were 11 wrong knee implant operations. The data also reports that 11 patients were overdosed on insulin and 7 patients received wrong blood transfusions.

 

A further 29 serious incidents were noted by the Trusts but did not appear to meet the definition of a ‘Never Event’.

 

There are three hospital trusts where the number of ‘Never Events’ have reached double digits. Manchester University NHS Foundation Trust reported 11 ‘Never Events’ last year, the most of all the Trusts. Four of these were because of performing surgery on the wrong site on the body. Nottingham University Hospitals NHS Trust and Sandwell and West Birmingham University Hospitals NHS Trust both reported 10 ‘Never Events’ each.

 

NHS England states that the concept of ‘Never Events’ is not about apportioning blame to organisations when these incidents occur but rather to learn from what happened. They believe that the more NHS staff take the time to report incidents is good evidence that this learning is happening locally.

 

You can view or download the full report from the NHS England website here.

 

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