| Type of incident | Number of events |
|---|---|
| Wrong site surgery |
5
|
| Wrong implant/prosthesis |
11
|
| Retained foreign object post procedure |
2
|
| Mis-selection of a strong potassium solution |
1
|
| Administration of medication by the wrong route |
2
|
Dr Andrew Vallance-Owen, Chair of PHIN, said: “The publication of these Never Events is an important step-change in transparency. This will be helpful for patients when deciding the right provider for their care, but it is also important that the information is available to hospitals, consultants and others within the sector.
“Never Events have to be reported so that lessons are learnt and actions taken to ensure they cannot happen again. This means that the reporting, investigation and learning is a powerful safety ‘call to action’ in itself and should always lead to an improvement in processes and quality of care as a result.”We hope publication of this information will stimulate that process of continuous improvement.”
The NHS Improvement definition of a Never Event says that such incidents “are wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and have been implemented by healthcare providers”.
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