References

Care Quality Commission. Opening the door to change NHS safety culture and the need for transformation. 2018. https://tinyurl.com/y24ub9q7 (accessed 28 June 2021)

Healthcare Safety Investigation Branch. Wrong site surgery—wrong patient: invasive procedures in outpatient settings (I2019/018). 2021a. https://tinyurl.com/p6m4pjpc (accessed 28 June 2021)

Healthcare Safety Investigation Branch. National Learning Report. Never Events: analysis of HSIB's national investigations (I2020/006). 2021b. https://tinyurl.com/262ec9ak (accessed 28 June 2021)

Healthcare Safety Investigation Branch. Never events: analysis of HSIB's national investigations. 2021c. https://tinyurl.com/9amuevkc (accessed 28 June 2021)

NHS England/NHS Improvement. Provisional publication of Never Events reported as occurring between 1 and 30 April 2021. 2021. https://tinyurl.com/3br2hnj5 (accessed 28 June 2021)

NHS Improvement. Never Events policy and framework. 2018. https://tinyurl.com/zh2v3kn4 (accessed 28 June 2021)

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The never-ending story of Never Events in the NHS

08 July 2021
6 min read
Volume 30 · Issue 13

Abstract

John Tingle, Lecturer in Law, Birmingham Law School, University of Birmingham, discusses several recent publications on Never Events in the NHS

One major patient safety metric that helps us judge the safety of a hospital or other healthcare facility is the number of Never Events that occur. In the NHS patient safety vocabulary, the term ‘Never Event’ has an officially ascribed meaning and there is a policy framework that helps unpack the concept (NHS Improvement, 2018). In this, the following definition is given:

‘Never Events are defined as Serious Incidents that are wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers.’

NHS Improvement, 2018:4

However, later guidance has this definition:

‘Never Events are serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations.’

NHS England/NHS Improvement, 2021:2

The phrase ‘largely preventable’ is used in this later publication, as opposed to ‘wholly’ preventable in the 2018 framework.

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