Never Events
Definition and purpose
Never Events are serious, largely preventable patient‑safety incidents that should not occur when recognised safety practices and systems are in place.
In the NHS they are listed in national policy and attract mandatory reporting, investigation and organisational learning designed to eliminate wholly avoidable harm (NHS Never Events policy).
Investigations must emphasise system‑level learning and improvement rather than individual blame (Patient Safety Incident Response Framework - PSIRF) (DHSC review).
Official list - common items to learn
The national list evolves; always check the current NHS list before governance or reporting decisions. The items below reflect commonly tested Never Events (grouped for learning):
- Surgical and procedural
- Wrong‑site, wrong‑procedure or wrong‑patient surgery.
- Wrong implant/prosthesis (including wrong intraocular lens, joint prosthesis, spinal implant).
- Retained foreign object after a procedure (swab, instrument, needle).
- Medication‑related
- Mis‑selection or administration of concentrated potassium solutions (wrong strength or route).
- Administration of medication by the wrong route (for example, enteral medication given intravenously).
- Insulin overdose attributable to prescribing or administration error (abbreviations, device misuse).
- Overdose of methotrexate when used for non‑cancer indications (for example, daily instead of weekly).
- Mis‑selection of high‑strength midazolam during conscious sedation.