References

Care Quality Commission. Opening the door to change. NHS safety culture and the need for transformation. 2018. https://tinyurl.com/mrxkznhy (accessed 15 June 2022)

5 reasons your frontline needs pre-shift team huddles. 2022. https://tinyurl.com/yc34a4dn (accessed 15 June 2022)

Healthcare Safety Investigation Branch. Never Events: analysis of HSIB's national investigations. 2021. https://tinyurl.com/2xmsthd5 (accessed 15 June 2022)

ITN News. Eight ‘Never Events’ reported at Royal Cornwall Hospitals. 2020. https://tinyurl.com/y3bh6sy5 (accessed 15 June 2022)

NHS England/NHS Improvement. Provisional publication of Never Events reported as occurring between 01 April 2020 and 31 March 2021. 2021. https://tinyurl.com/3xavfwys (accessed 15 June 2022)

NHS England/NHS Improvement. Provisional publication of Never Events reported as occurring between 1 April 2021 and 31 March 2022. 2022. https://tinyurl.com/2p973ybu (accessed 15 June 2022)

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Ways of tackling the continuing problem of Never Events

23 June 2022
6 min read
Volume 31 · Issue 12

Abstract

John Tingle, Lecturer in Law, Birmingham Law School, University of Birmingham, discusses the latest figures on Never Events, along with some other patient safety reports

I was giving a presentation at a patient safety event recently on Never Events and somebody mentioned to me how Never Events could now be referred to as ‘Always Events’. I have heard the term ‘Common Never Events' and have used that term myself in previous columns, but the concept of Always Events was new to me and shocking. This raises the issue that Never Events have possibly now become so commonplace in the NHS that they are part of everyday practice and do not hold the significance they once had. Are Never Events morphing from ‘Common’ to ‘Always’ Never Events?

In its seminal report, Opening the Door to Change, the Care Quality Commission (CQC) (2018) stated:

‘What sets Never Events apart is that they are believed to be wholly preventable by the implementation of the appropriate safety protocols. Despite this preventability, the number of Never Events has not fallen. About 500 times each year we are not preventing the preventable.’

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