WTP6.8 A Decade of NHS Never Events – Has formal reporting made a difference?

Abstract

Abstract Introduction NHS England defines “Never Events” (NE) as 'patient safety incidents that 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'. NHS Organisations were required to publish data on NE from April 2012. This project aims to identify changes in NE patterns to help inform future learning. Methods All published data between April 2012 and March 2022 was collected from NHS England. Data processing and manipulation was carried out using Microsoft Excel. Results A total of n=4,055 NE and n=175,920,530 procedures were reported. During the 2020-2021 year there were significantly less (p=0.029) NE compared to 2019-2020, however the rate of NE per million procedures (25 vs 27) remained unchanged p=0.18. Overall, there appears to be an increasing trend in NE, p<0.001. The majority of NE related to wrong site surgery, n=1,628(40%), retained foreign objects, n=1,090(27%) and wrong implant/prosthesis, n=506(12%), p<0.001. Within wrong site surgery, the most common NE was wrong procedure, n=529(32%), followed by laterality errors, n=391(24%), p<0.001. Discussion & Conclusion The results demonstrate that despite systemic protective barriers such as the WHO Checklist, overall rate of NE has not reduced. This is likely to be confounded by changes in reporting as well as definitions, for example from April 2021 wrong tooth extraction was not considered a NE. The importance of Human Factors must not be overlooked, and NHS Trusts should consider formal provision of such training for all those in clinical roles.