Clinical Negligence List of Never Events 2015/16

18th March 2016

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Never Events are serious incidents that are preventable due to guidance or safety recommendations that should be implemented by all healthcare providers.

The following never events list is the list that all organisations providing NHS care should use. It is applicable for all incidents that occur on or after 1 April 2015.

List of Never Events

  1. Wrong site surgery

    This may be at the wrong place on the body, or a procedure being carried out on the wrong patient.

    Included is incorrect spinal surgery, incorrect spinal blocks, erroneous biopsies, interventional procedures conducted by radiological services, and the placement of central access venous lines, e.g. Hickman lines.

  2. Wrong implant/prosthesis

    This includes the situation where the wrong implant/prosthesis is inserted.

  3. Residual foreign object post-procedure

    ‘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 guide wires)

  4. Mis-selection of a strong potassium containing solution

    e.g. When intravenous administration of strong potassium chloride has occurred;

  5. Incorrect administration of medication by the wrong route

    e.g. Intravenous chemotherapy administered via the intrathecal route or IV administration of a medicine intended to be administered via the epidural route;

  6. Overdose of Insulin due to abbreviations or incorrect device;

  7. Overdose of methotrexate for non-cancer treatment;

    When this occurs by any route, (either as the intended dosage but for the wrong route, or the completely the wrong dose);

  8. Mis-selection of high strength midazolam during conscious sedation;

  9. Failure to install functional collapsible shower or curtain rails;

    i.e. in the circumstances of an inpatient trying to commit suicide by hanging from a collapsible curtain or shower rail not collapsing.

  10. Falls from poorly restricted windows

    e.g. where limited opening windows have been damaged previously, reported but not repaired has led the patient to be able to jump

  11. Chest or neck entrapment in bedrails

    When a patient becomes stuff in the bedrails, between them, the bedframe of mattress (and those pieces of apparatus not fulfilling the requirements of the Medicines and Healthcare products Regulatory Agency (MHRA) guidance.

  12. Transfusion or transplantation of ABO-incompatible blood components or organs, such as the unintentional transfusion of ABO-incompatible blood components, or the transplantation of unintentional ABO mismatched solid organ(s).

  13. Misplaced naso- or oro-gastric tubes

    The placement of a naso- or orogastric tube in the respiratory tree and its location not confirmed as being in the wrong place prior to feeding or the administration of medicines via this route

  14. Scalding of patients such as by hot water as used for washing or bathing.

Who to Contact

Should you have any questions or queries regarding the the List of Never Events, please contact any member of the Medical Negligence Team.




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Rachel Kirby


Associate, Cardiff

+44 (0)29 2039 1886