NPSA publishes data on ‘Never Events’

The National Patient Safety Agency (NPSA) has published its first ever national report on Never Events.

Never Events are patient safety incidents that are preventable because: there is guidance that explains what the care or treatment should be; there is guidance to explain how risks and harm can be prevented; there has been adequate notice and support to put systems in place to prevent them from happening.

The NPSA definition of a Never Event is: A serious, largely preventable patient safety incident that should not occur if the available preventative measures have been implemented by healthcare providers.

Never Events are one of the indicators that can be used to demonstrate how safe an organisation is and its patient safety culture. Continued occurrence of Never Events can be considered an indicator of an organisation that has not put the right systems and processes in place to prevent them from happening.

A total of 111 Never Events were reported to the NRLS at the NPSA. In summary:

– The Never Events were spread throughout England, occurred throughout the year and across different trusts.

– Just over half were related to wrong site surgery (57).

– The second highest reported Never Event was related to misplaced naso or orogastric tubes (41).

– There were no reports of Never Events related 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 remaining three Never Events had fewer than 10 events reported over the year.

Download the NPSA’s Never Events Annual report 2009/10 here.

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