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In healthcare, we often talk about 'never events'—serious incidents that should not occur if appropriate systems are in place. But what happens when they do occur? I recently had the great pleasure of working with a group of anaesthetic resident doctor colleagues on a patient safety project that began with exactly that question. Within a short period in 2025, our large UK teaching hospital experienced two wrong-sided peripheral nerve blocks after six years without a single reported incident. We wanted to understand why. Looking beyond individual error Both incidents occurred during a major transition: we were moving anaesthetic records, consent forms and safety checklists from paper to digital. At first glance, the timing felt more than coincidental. After initial governance processes were completed, our team used the Patient Safety Incident Response Framework (PSIRF)[1] to explore what had happened. Introduced in the NHS in 2022, PSIRF promotes a systems-based approach rather than searching for a single 'root cause'. It examines how elements such as people, tasks, tools and technology, environment and organisational factors interact to increase risk. For us, this shift in perspective proved crucial. Instead of asking “who made this mistake?”, we were able to consider “what conditions made this error more likely?”. What we found: small gaps in a complex system We brought together a multidisciplinary 'learning MDT', combining insights from staff interviews and systems analysis. A clear pattern emerged: no single failure caused these incidents. Instead, multiple small vulnerabilities aligned. One issue stood out. In our previous paper-based system, clinicians used a 'Stop Before You Block' (SBYB) sticker—a simple but effective visual cue prompting a final safety pause before performing a nerve block. During the digital transition, this physical prompt disappeared. Other contributing factors reinforced the problem: Staff worked under cognitive overload, juggling interruptions, changing plans and high-acuity patients. Digital consent processes made SBYB checks feel more cumbersome, drawing attention away from the patient and towards the computer. Poor visibility of surgical site markings increased the barriers to performing SBYB. Ergonomic challenges in anaesthetic rooms made equipment setup frustrating. Time pressure on theatre lists encouraged task compression. In both cases, clinicians skipped the SBYB pause entirely—not out of negligence, but because the system no longer reliably supported it. These events didn’t reflect individual failure. They reflected a system under strain during organisational change. From insight to action: designing safer systems We knew we couldn’t eliminate complexity from clinical environments, but we could design systems that make the safe action the easy action. We developed a multi-faceted improvement plan. 1. Strengthening standards and education We updated our local guidance, aligning it with national recommendations from the Safe Anaesthesia Liaison Group and Regional Anaesthesia UK.[2] We rebranded it as the 'Prep Stop Block LocSSIP' (Local Safety Standard for Invasive Procedures). We promoted this through clinical governance meetings and delivered targeted teaching to consultants, trainees and anaesthetic practitioners. To support sustainability, we embedded a training video into the anaesthetic resident doctor induction programme and uploaded it to our intranet. 2. Fixing friction in the system We addressed practical barriers: Improved access to longer ultrasound cables. Standardised surgical site markings to improve visibility. Explored integrating anaesthetic complexity into theatre scheduling. Trialled LED signs to indicate when the anaesthetic room is in use; thus creating a 'sterile cockpit' by discouraging interruptions during anaesthetic procedures. Introduced electronic tablets so consent forms could be viewed alongside the patient and checklist. Each of these changes aimed to reduce cognitive load and create space for safer practice. 3. Introducing a physical safety barrier Our most impactful intervention was the 'Prep Stop Block Lid'. We designed a lidded box displaying a safety infographic. Clinicians place prepared local anaesthetic inside and cannot access it until they complete the SBYB pause. This shifts safety from memory to physical design, creating a clear pause point in the workflow. We refined the intervention through Plan–Do–Study–Act (PDSA) cycles with frontline feedback before wider rollout. What we’ve learned so far Early data show improvements in process measures, including increased visibility of the SBYB step. Audits of Prep-Stop-Block compliance suggest an improvement from 34% during digital transition to 100% at most recent review. However, we remain cautious. We are still in a 'zone of vulnerability', where changes are ongoing and their full impact is unclear. Because never events are (fortunately) rare, it will take time to determine whether these interventions reduce harm. That said, several key lessons have already emerged: Never events are rarely about individuals. They arise from system conditions that make errors more likely. Digital transformation can unintentionally remove safety cues. We must actively design these back into new systems. Education and policy are necessary but insufficient. The most reliable safety interventions are embedded into workflow, especially physical or procedural 'forcing functions'. A call to action If your department is undergoing digital transformation, take a moment to ask: “What safety cues might we be losing—and how will we replace them?” We need to move beyond simply digitalising existing processes. Instead, we should use these transitions as opportunities to design safer, more resilient systems from the ground up. Because when it comes to patient safety, 'never' is not a guarantee, it’s a goal we must actively work towards. References https://www.england.nhs.uk/long-read/patient-safety-incident-response-framework/ https://www.salg.ac.uk/salg-publications/stop-before-you-block/

hub topic lead Richard Jones highlights an incident where the sepsis warning AI system failed to highlight a patient's deterioration and led to an avoidable death. I'll hide the location of this tragic story. A busy nurse was doing her evening rounds. The ward was short on staff and so the nurse took some observations and put them on her uniform as a Post-It note. She'd enter the data later. The patient had cancer and was heavily immunocompromised. The nurse got back around to the patient and took further observations. She then went to enter them in the system. The AI in the system had been trained to understand that two observations so close (in time) was an issue and so it ignored one. This meant it did not enter the details of the patient's vitals that showed the patient had an issue (sepsis). The patient was given an Amber alert status instead of a Red one. The next day the patient died. The nurse was not at fault. You could argue the system was not at fault. However, it lacked 'real-world' experience of how nurses operate. The learning point here? I'm not sure. Mindless reliance on systems to spot the things we miss is unhelpful but I have never regretted a conversation with a nurse regarding how they work and how they care.

Nasogastric tube (NGT) safety has been a pressing issue for over two decades, with the first Patient Safety Alert (PSA) issued back in 2005, drawing attention to the dangers of misplaced NGTs. Despite subsequent alerts, reports, and detailed studies — including an investigation by the Health Service Safety Investigation Body (HSSIB) in 2020 — little progress has been made, and misplaced NGTs still rank high on the list of Never Events. Now is the time for change. This free webinar we will discuss the latest developments and actionable strategies to address these ongoing challenges. Register

NHS England is currently seeking views on whether the existing Never Events Framework remains an effective mechanism to drive patient safety improvement. Never Events are defined as patient safety incidents that are ‘wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers’. This webinar, hosted by the National NatSSIPs Network and supported by Patient Safety Learning, will feature a panel discussion on the Never Events framework and the proposals set out in this consultation. The National NatSSIPs Network is a group of healthcare professionals aiming to reduce the number of patient safety incidents related to invasive procedures. Speakers: Helen Hughes Dr Annie Hunningher Dr Sam Machen Claire Cox Guest Speaker Guest Speaker Register

Understanding human factors will allow surgical teams to enhance performance, culture and organisation of operating theatres. This one day masterclass will concentrate on human factors within the operating room. This is aimed at all theatre staff. It will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. This Masterclass will focus on systems to improve patient safety as well as looking at never events and how to learn from them using a human factors approach. Key learning objectives: Safety culture Human factors Leadership Never events This masterclass is aimed at all theatre staff. Register hub members receive 20% discount using code hcuk20kh.

Never events are defined as “serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations.” They are designed to act as a red flag for improvement by NHS organisations. This one day masterclass will focus on safety culture around Never Events within healthcare organisations. There were 364 never events in 2020/21 and 349 between April 2021 and Jan 2022. The masterclass will look at how Never Events have been investigated and at Human Factors approaches to improving learning and the systems to reduce harm. It will compare our experiences with learning from serious incidents from other countries. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/learning-from-never-events or email [email protected]. hub members receive a 20% discount, Email [email protected] for discount code.

Never Events and serious Incidents are a cause for concern and anxiety when reported in an organisation. They require investigation and official reporting to the Care Quality Commision (CQC). The end result should be a process of open multidisciplinary analysis and discussion led by the Clinical Governance team that results in learning for the organisation. This process can be difficult and sensitive when harm is identified and errors attributed to processes and individual staff. In this webinar, we welcome representatives from the CQC and the National Orthopaedic Alliance (NOA) to discuss learning from never events and serious incidents. Register

This Q Community session: Introduces the concepts and origins of ‘never events’ and ‘zero harm’ as safety interventions. Explores and debates the usefulness of ‘never event’ and ‘zero harm’ initiatives as effective safety management strategies in healthcare. Reflects on and considers alternative approaches to managing risks of serious harm to as low as reasonably practicable. Further information Register