Never Events are patient safety incidents that are considered preventable when national guidance or safety recommendations that provide strong systemic protective barriers are implemented by healthcare providers.
The cases analysed here include 20 of surgery at the wrong site; 4 of the wrong implant being inserted; and 14 of retained foreign objects. It is important to note that these cases represent a small fraction of the total number of interventional procedures undertaken in the NHS and independent sector during the year in question.
NHS Improvement: Surgical never events. Learning from 38 cases occurring in English hospitals between April 2016 and March 2017 https://improvement.nhs.uk/documents/3213/Learning_from_surgical_Never_Events_FINAL.pdf
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