Never events: what's on your list of ensuring patient safety?

I was talking about Never Events at a dinner party, trying to explain what they are, and two friends were horrified - at the concept that in healthcare we need to draw up a list of things that should never happen.  I agree, as a patient the list below does feel scary - not because they might happen, but because we need to talk about them not happening...


The NHS in England has just expanded the list to 26 from 8 (details are in this policy document); I'm still not sure whether this is a good thing or not.I have heard that some countries and regions don't bother with Never events lists. I'd be interested in finding out whether they do this for a reason.

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-naïve 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)

Fear of failure? Never Events need a target of zero

So how would you feel if you were the patient of a surgical team whose improvement target for the "Never" event of wrong site surgery was - to reduce by 20%? A "Never" event is something that, by definition, should never happen. The NHS in England have a list of 8 that are so well evidenced they should be adopted for implementation with no further discussion.

Why then are we seeing targets for Never Events that are not zero? My recent experiences suggest the following dynamics at play:

• zero is too difficult a target to achieve in healthcare (try telling that to the patient who has just had their wrong kidney removed or the suicide that happened when on 1-1 watch and using non-collapsible rails). Admittedly in some healthcare processes zero may be a tough tartget, however, Never Events mean never.
• we may not meet the target (fear the failure and the knock on consequences for individuals, teams and project work); when I encounter this I realise I am working with an individual or group who fear the failure of improvement greater than they feal the failure of harming a patient.
• it's not worth all the changes for zero (the costs of the change outweight the cost of full redeuction of a never event); this is, of course, a judgement call and my hope is it is made with full data analysis and consultation of those involved. Some never events happen so seldom it may be difficult to justify the changes required.
• we don't believe the research is good enough; the NHS in England (National Patient Safety Agency) have streamlines a varietyof Never Event lists to determine a core 8 which are well proven in all aspects. More research I suggest is not required.
• we will take a while to get to zero; that's ok, then let's see a desired outcome of zero and some leeway to reduce over time. The trick is perhaps not to design for a 20% reduction in year 1 but rather to design for zero in year 3 and monitor progress over time.

Never events need targets of Zero - 0. They should never happen.