Policy paper

The 'never events' list for 2011/12

"Never events" are very serious, largely preventable patient safety incidents that should not occur if the relevant preventative measures have been put in place. This paper sets out the final expanded list for use in the NHS in 2011/12 and provides further guidance for how the "never events" policy should be implemented.

Documents

The 'Never Events' list for 2011-12

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Equality impact assessment

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Detail

An updated list of the ”never events” list for 2012/13 was published on 18 January 2012.

The Government proposed in last year’s White Paper to expand the current list of incidents considered to be “never events”. A draft list of “never events” was published in October 2010, and comments were sought on the proposals. Following this engagement process, the list was revised and the policy clarified. This paper therefore sets out the final expanded list for use in the NHS in 2011/12 and provides further guidance for how the “never events” policy should be implemented.

This policy paper should be used in conjunction with the NHS Standard Contracts 2011/12.

There are 25 “never events” on the expanded list. This includes the original eight events from previous years, some of which have been modified, and builds on the draft list published in October 2010. The list is as follows:

  1. Wrong site surgery (existing)
  2. Wrong implant/prosthesis (new)
  3. Retained foreign object post-operation (existing)
  4. Wrongly prepared high-risk injectable medication (new)
  5. Maladministration of potassium-containing solutions (modified)
  6. Wrong route administration of chemotherapy (existing)
  7. Wrong route administration of oral/enteral treatment (new)
  8. Intravenous administration of epidural medication (new)
  9. Maladministration of Insulin (new)
  10. Overdose of midazolam during conscious sedation (new)
  11. Opioid overdose of an opioid-naive patient (new)
  12. Inappropriate administration of daily oral methotrexate (new)
  13. Suicide using non-collapsible rails (existing)
  14. Escape of a transferred prisoner (existing)
  15. Falls from unrestricted windows (new)
  16. Entrapment in bedrails (new)
  17. Transfusion of ABO-incompatible blood components (new)
  18. Transplantation of ABO or HLA-incompatible Organs (new)
  19. Misplaced naso- or oro-gastric tubes (modified)
  20. Wrong gas administered (new)
  21. Failure to monitor and respond to oxygen saturation (new)
  22. Air embolism (new)
  23. Misidentification of patients (new)
  24. Severe scalding of patients (new)
  25. Maternal death due to post partum haemorrhage after elective Caesarean  section (modified)

General queries on the ‘never events’ policy can be emailed to neverevents@dh.gsi.gov.uk

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