Provisional publication of Never Events reported as occurring between 1 April 2021 and 31 March 2022

Summary

Never Events are serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations. This document details Never Events that were reported by NHS trusts in England between 1 April 2021 and 31 March 2022. Never Events are categorised by type of incident and by trust.

Content

Never Events 1 April 2021 – 31 March 2022 by type of incident:

• Wrong site surgery – 171
• Retained foreign object post procedure – 98
• Wrong implant/prosthesis – 47
• Misplaced naso or oro gastric tubes and feed administered – 31
• Administration of medication by the wrong route – 21
• Unintentional connection of a patient requiring oxygen to an air flowmeter – 13
• Overdose of insulin due to abbreviations or incorrect device – 11
• Transfusion or transplantation of ABO incompatible blood components or organs – 7
• Falls from poorly restricted windows – 3
• Mis selection of high strength midazolam during conscious sedation – 2
• Overdose of methotrexate for non-cancer treatment – 2
• Mis selection of a strong potassium solution - 1