About patient safety never events

What are patient safety never events?

Never Events (known in the healthcare system as an ‘adverse event’) are serious, preventable incidents where a patient has been put at an unnecessary risk and possibly serious harm. While hospitals can’t prevent all harm to patients, never events are incidents which shouldn’t happen if the right processes are in place for patient care. Healthcare professionals have to report these patient safety incidents, even if the incident doesn’t lead to patient harm.

There are three categories of never events:

• Surgical never events include incidents which take place in surgery, such as the surgeon operating on the wrong part of the body, inserting the wrong implant or operating on the wrong patient.
• Medication never events are where patients have been administered the wrong type or dosage of a medication, or the way the medication was administered was wrong.
• General never events are other incidents which include health and safety incidents, such as a patient becoming trapped in a hospital bed.

Why do hospitals record never events?

Healthcare providers are required to record and investigate all never events that take place. The investigations are used to help hospitals understand what went wrong and put in place processes to prevent similar incidents from happening in the future.

Hospitals are required to keep records on the number of never events that happen to NHS funded patients and to report information about them to NHS Improvement. Any hospitals treating privately funded patients are required to report these never events to PHIN.

What can never events tell you about a hospital?

The first thing you should look for is whether the hospital is monitoring and reporting their never events at all. Hospitals that record and report never events are likely to have a strong focus on patient safety and learning from past mistakes.

If a hospital does not record and report serious safety incidents, this may lead you to question their care quality and whether they adequately monitor safety in their hospitals, and what this might mean for your care.

If a hospital has reported one or more never event, you may want to ask what actions were taken to stop it happening again and how this could affect you.

The never events that are on our website cannot tell you the full story of what is going on at each hospital, so this information is best used during discussions with your consultant or hospital. 

Your checklist

1. Check whether your local hospital is reporting their never events. If they aren’t, what does this say about safety in the hospital, and what could this mean for your care?
2. Understand your hospital’s never events. If your hospital has recorded never events, what type of incident was it, what did they do about it and might this be relevant to your care?
3. Ask questions. Use our information and the published numbers to ask your GP or consultant about the hospital’s safety procedures. You need to be confident that they are the right hospital for you.