The ‘never events’ list has been updated and published with minor amendments to two of the never event definitions.
The changes are to ‘never event’ number 18, ‘Transplantation of ABO incompatible organs as a result of error’ and ‘never event’ number 23, ‘Misidentification of patients’. The never events list for 2012/13
sets out the revised list and definitions for use in the NHS in 2012/13.
Please note that the policy framework published in February 2011 is still valid, apart from the update to the definitions in the “never events” list. The policy framework and associated equalities assessment).
The full ‘never events’ list for reference is:
- 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-naive 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.