The term ‘never event’ was first introduced in 2001 by Ken Kizer, former chief executive of the National Quality Forum in the United States, in reference to particularly shocking medical errors that should never occur.
Over time, the term has been expanded to signify adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable if the available measures have been implemented by healthcare providers.
The information from the United States indicates that the use of the term and its associated focus has improved safety.
In the UK the term was introduced in April 2009, following Lord Darzi’s proposal in High Quality Care for All. The original list consisted of the following:
- Wrong site surgery
- Retained instrument post-operation (includes swabs and throat packs)
- Wrong route administration of chemotherapy
- Misplaced naso or orogastric tube not detected prior to use
- In-hospital maternal death from post-partum haemorrhage after caesarean section
- Inpatient suicide using non-collapsible rails
- Escape from within the secure perimeter of medium or high secure mental health services by patients who are transferred prisoners
- Intravenous administration of mis-selected concentrated potassium chloride.
To be a never event, an incident must fulfil the following criteria:
- It has clear potential for, or has caused severe harm or death.
- There is evidence that it has occurred in the past (ie, it is a known source of risk).
- There is existing national guidance or safety recommendations on how it can be prevented and there is support for implementing these.
- It can be easily defined, identified and continually measured.
Serious events (including never events) are assessed and categorised as grade 1 or 2, depending on the seriousness of the event. They should all be reported to the primary care trust (or clinical commissioning group), as well as the National Reporting and Learning Service (NRLS – at Imperial College), with never events being specified in the free text field. Since the summer, reports should also be made to the Strategic Executive Information System.
Although such events are reported to CQC and Monitor through the NRLS, it is much better if they are reported directly to CQC (and Monitor for foundation trusts and the NHS Trust Development Authority for non-foundation trusts). Serious events are investigated and shared with the PCT and an action plan shared widely to improve the service.
CQC may use information on never events to inform our regulatory processes, alongside other indicators, and we may take enforcement action.
In the first year of reporting, there were 111 never events. Of these, 57 were due to wrong site surgery, and 41 due to misplaced nasogastric tubes. There were no events due to wrong route administration of chemotherapy, in-hospital maternal death from post-partum haemorrhage after elective caesarean section, and inpatient suicide using non-collapsible rails. The remainder were under 10 events.
We would all agree that the national reporting system is in dire need of revision to ensure that it becomes a true national learning experience.
There has been a recent review of never events and the list extended to the following:
- Wrong site surgery
- Wrong implant/prosthesis
- Retained foreign object post-operation
- Wrongly prepared high-risk injectable medication
- Maladministration of potassium-containing solutions
- Wrong route administration of chemotherapy
- Wrong route administration of oral/enteral treatment
- Intravenous administration of epidural medication
- Maladministration of insulin
- Overdose of midazolam during conscious sedation
- Opioid overdose of an opioid-naïve patient
- Inappropriate administration of daily oral methotrexate
- Suicide using non-collapsible rails
- Escape of a transferred prisoner
- Falls from unrestricted windows
- Entrapment in bedrails
- Transfusion of ABO-incompatible blood components
- Transplantation of ABO-incompatible organs as a result of error
- Misplaced naso- or oro-gastric tubes
- Wrong gas administered
- Failure to monitor and respond to oxygen saturation
- Air embolism
- Misidentification of patients
- Severe scalding of patients
- Maternal death due to post partum haemorrhage after elective Caesarean section.
The bolded ones would be more appropriate for the Emergency Department.
Input from CQC
What are Never Events?
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