A 'never event' is a serious, preventable mistake made by healthcare staff that puts the patient at serious risk of harm or death.
To be a 'never event', an incident must fulfill the following criteria:
- The incident has the clear potential for, or has caused severe harm or death
- There is evidence of occurrence in the past (i.e. it is a known source of risk)
- There is existing guidance to prevent the event
- The event is largely preventable if the guidance is implemented
Announced inspectors at Derriford Hospital in Plymouth discovered eight 'never events' during their two week visit.
- Seven of the incidents took place in theatre
- Four of the incidents included wrong site surgery: i.e surgeons operated on the wrong part of a patient's body