News story

Never events list update for 2012/13

The ‘never events’ list has been updated and published with minor amendments to two of the never event definitions.

• From: Department of Health and Social Care
• Published: 20 January 2012

This was published under the 2010 to 2015 Conservative and Liberal Democrat coalition government

The changes are to ‘never event’ number 18, ‘Transplantation of ABO incompatible organs as a result of error’ and ‘never event’ number 23, ‘Misidentification of patients’.  The never events list for 2012/13
sets out the revised list and definitions for use in the NHS in 2012/13.

Please note that the policy framework published in February 2011 is still valid, apart from the update to the definitions in the “never events” list. The policy framework and associated equalities assessment).

The full ‘never events’ list for reference is:

1. wrong site surgery
2. wrong implant/prosthesis
3. retained foreign object post-operation
4. wrongly prepared high-risk injectable medication
5. maladministration of potassium-containing solutions
6. wrong route administration of chemotherapy
7. wrong route administration of oral/enteral treatment
8. intravenous administration of epidural medication
9. maladministration of Insulin
10. overdose of midazolam during conscious sedation
11. opioid overdose of an opioid-naive patient
12. inappropriate administration of daily oral methotrexate
13. suicide using non-collapsible rails
14. escape of a transferred prisoner
15. falls from unrestricted windows
16. entrapment in bedrails
17. transfusion of ABO-incompatible blood components
18. transplantation of ABO-incompatible organs as a result of error
19. misplaced naso- or oro-gastric tubes
20. wrong gas administered
21. failure to monitor and respond to oxygen saturation
22. air embolism
23. misidentification of patients
24. severe scalding of patients
25. maternal death due to post partum haemorrhage after elective Caesarean section.

Published 20 January 2012