Never events: analysis of HSIB's national investigations

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

This national learning report analyses the findings of the investigations previously carried out by HSIB concerning incidents classified as never events.

Our national learning reports can be used by healthcare leaders, policymakers, and the public to:

• Aid their knowledge of systemic patient safety risks
• Understand the underlying contributing factors
• Inform decision making to improve patient safety

The information in these reports is also used to inform future HSIB investigations or programmes of work.

Never events

‘Never events’ are patient safety incidents that are defined as being wholly preventable. They are considered wholly preventable because guidance or safety recommendations are in place at a national level and should have been implemented by all providers in the healthcare system. This should act as a strong systemic barrier to prevent the serious incident from happening.

Summary

In this national learning report, our previous never event national investigation reports have been analysed to look at themes in the factors that contributed to these incidents happening.

Our previous published never event national investigation reports include:

• Piped supply of medical air and oxygen.
• Administering a wrong site nerve block.
• Detection of retained vaginal swabs and tampons following childbirth.
• Inadvertent administration of an oral liquid medicine into a vein.
• Insertion of an incorrect intraocular lens.
• Implantation of wrong prostheses during joint replacement surgery.

Our ongoing national investigations looking into never events include:

• Administering high strength insulin from a pen device in hospital.
• Placement of nasogastric tubes.
• Wrong site surgery – wrong tooth extraction.
• Wrong site surgery – wrong patient.

We are using the Safety Engineering Initiative for Patient Safety (SEIPS) model to carry out the analysis. SEIPS provides a framework for understanding structures, processes and outcomes in healthcare, and their relationships.