Never never land

The National Patient Safety Agency defines “never events” as serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been put in place by healthcare providers. The initial list of 8 “never events” included

• Wrong site surgery
• Retained instrumentation post-surgery
• Wrong route administration of chemotherapy
• Misplaced naso /oro-gastric tube not detected prior to use
• Maternal death from post partum haemorrhage following elective caesarean section
• Intra venous administration of mis-selected concentrated potassium chloride

A total of 111 never events were reported in 2009/10. Of these 57 related to wrong site surgery. This is despite the introduction of the “Surgical Safety Checklist”. A further 41 related to misplaced naso/oro-gastric tubes. Clearly the end of year report for the NHS should read “could do better.”

If you would like further advice on a potential clinical negligence claim please visit our website
Caroline Kerr, Solicitor, Clinical Negligence Department