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Revised Never Events Policy and Framework

Released on - 19/01/2018

 Revised Never Events Policy and Framework

A revised Never Events Policy and Framework was published on 17 January 2018.

The publication of a new Framework requires providers to take action to bring local policies and procedures in-line with the revised document. The revised Framework will become active upon initiation of the updated 2017-19 NHS Standard Contracton 1 February 2018.

Revisions to the Framework have been made following consultation with a wide range of stakeholders and the document offers a useful reference point for patients, boards, and all healthcare clinical and management staff. The focus of the policy remains one of learning and improvement.

The full document, updated list of Never Events and supporting information is available on the NHS Improvement website via the following link:

Revised Never Events Policy and Framework

 It is important that you read the document in full but the main changes are highlighted below:

Removal of the option for commissioners to impose financial sanctions on trusts when they report a Never Event

The consultation responses argued that the existence of an option for commissioners to impose financial sanctions following a Never Event reinforced the perception of a ‘blame culture’. This could lead to important lessons to improve patient safety both locally and nationally being lost due to an inappropriate focus on individuals.

Removal of the option to impose financial sanctions does not in any way signal a reduction in the focus that should be placed on preventing Never Events. This is about emphasising the importance of learning from their occurrence rather than using blame as a tool.

Incorporate future versions of the Never Events Framework into the wider Serious Incident Framework

The high profile that Never Events attract means there can be a disproportionate focus on Never Events, many of which are relatively low harm incidents compared to other Serious Incidents that cause greater harm.

NHS Improvement will soon begin an engagement exercise around the Serious Incident Framework with a view to publishing a revised version in 2018. The revised Serious Incident Framework will then incorporate the Never Events Policy and Framework.

A single Serious Incident Framework incorporating an agreed list of Never Events will provide an integrated framework, reducing the complexity and perceived need for organisations to take a different approach to tackling different kinds of Serious Incidents.

Changes to the Never Events list

A reference group comprising of NHS Improvement and NHS England regional quality leads, members of the NHS Improvement Patient Safety Team and clinical advisors reviewed the existing list of Never Events and new Never Events that had been proposed as part of the consultation.

For the existing list of Never Events, each definition was reviewed to ensure that it continued to meet the criteria for a Never Event and that the guidance listed was still current and relevant.

In addition, all new Never Events that had been proposed as part of the consultation were reviewed and this has resulted in two new Never Events being added to the list.

A summary of the changes we have made is below and the rationale for why these changes have been made can be found in the Never Events liston the NHS Improvement website.


Changes to existing list of Never Events

Never Event



Wrong site surgery

Include pain relief blocks

Wrong site surgery

Clarification that the extraction of primary (milk) teeth is excluded unless undertaken under a general anaesthetic

Wrong site surgery

Exclude spinal surgery

Wrong site surgery

Exclude contraceptive hormone in the wrong arm

Wrong implant/ prosthesis

Includes the implantation of an intra uterine contraceptive device that is different from the one intended in the procedural plan

Wrong implant/ prosthesis

Excludes where the implant/ prosthesis is different to the one intended due to incorrect pre procedural measurements or incorrect interpretation of the pre procedural data e.g. wrong intraocular lens due to wrong biometry or due to using wrong set of data from correct biometry

Overdose of insulin due to abbreviations or incorrect device

Include when a healthcare professional withdraws insulin from an insulin pen or an insulin pen refill and administers using a syringe and needle




New Never Events Never Event

Rationale for inclusion

Unintended connection of a patient requiring oxygen to an airflow meter

Guidance available in the form of a Patient Safety Alert Reducing the risk of oxygen tubing being connected to air flowmeters, NHS Improvement, 2016 , available at



Undetected oesophageal intubation

Guidance available to prevent the ventilation of a patient following intended tracheal intubation and subsequent oesophageal intubation that is not recognised or acted upon:

4th National Audit Project of The Royal College of Anaesthetists and The Difficult Airway Society (NAP 4) Major complications of airway management in the United Kingdom, 2011, available at

Standards of monitoring during anaesthesia and recovery, 2015, Association of Anaesthetists of Great Britain and Ireland (AAGBI)



This revised Never Events policy and Framework is intended as a further step towards developing an open and honest NHS that learns from when things go wrong, so we can improve the care we provide and keep our patients safe.

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