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Serious Injury (Never Event)

Serious Injury (Never Event)

A never event is the “kind of mistake (medical error) that should never happen” in the field of medical treatment. These are serious, largely preventable events but have terrible consequences for the patient.

Doctors and nurses are encouraged to learn from mistakes. Any hospital that reports a Never Event is expected to conduct its own investigation so it can learn and take action on the underlying causes. They are encouraged to apologised. Yet the event is often so serious as to leave the patient with life changing injury.

The figures are alarmingly consistent year on year:

• Never Events 1 April 2016 to 31 March 2017 there were 445
• Events 1 April 2017 to 31 January 2018 there were 407
• From 1 April 2019 to 31 March 2020 there were 472

What is a Serious Injury (Never Events)

There are currently 25 specified never events, of which only three have been defined as ‘surgical’ never events.

Wrong site surgery

A surgical intervention performed on the wrong site (for example wrong knee, wrong eye, wrong patient, wrong limb, or wrong organ). The incident is detected at any time after the start of the operation and the patient requires further surgery, on the correct site, and/or may have complications following the wrong surgery.

This includes biopsy, radiological procedures and drain insertion, where the intervention is considered surgical.

Wrong implant

Surgical placement of the wrong implant or prosthesis where the implant/prosthesis placed in the patient is other than that specified in the operating plan either prior to or during the procedure. The incident is detected at any time after the implant/prosthesis is placed in the patient and the patient requires further surgery to replace the incorrect implant/prosthesis and/or suffers complications following the surgery.

Retained foreign object post-procedure

Retention of a foreign object in a patient after a surgical/ invasive procedure. ‘Surgical/ invasive procedure’ includes interventional radiology, cardiology and interventions related to vaginal birth. ‘Foreign object’ includes any items that should be subject to a formal counting/ checking process at the commencement of the procedure and a counting/ checking process before the procedure is completed (such as swabs, needles, instruments and guidewires) except where:

Other Serious Injury (Never Events)

1. Unintentional connection of a patient requiring oxygen to an air flowmeter
2. Misplaced naso or oro gastric tube
3. Administration of medication by the wrong route
4. Oral medication given intravenously
5. Mis selection of high strength midazolam during conscious sedation
6. Overdose of methotrexate for non-cancer treatment
7. Overdose of insulin due to abbreviations or incorrect device
8. Wrong syringe
9. Wrong blood transfused

The distress these errors cause to patients and their families is significant. Patients don’t go into hospital expecting errors to occur and rightly anticipate that their entire experience will be safe and error-free. With the use of checklists in the theatre and provision of patient notes once would hope that such serious injury from Never Events could not occur but they do. Many patients die as a result of these events.

It is so very important that the patient (or family) receive a sincere apology, and an explanation of what went wrong and how it will be put right. This is every doctor’s ethical duty, and now also a contractual obligation under the duty of candour.

Preventable things can and do go wrong, sometimes with severe consequences for the patient.