NHS ‘Never Event’ Mistakes Are Not Yet Truly Preventable, According To Safety Watchdog

The independent Healthcare Safety Investigation Branch (HSIB) says labelling some mistakes as never events could fuel a blame culture in the health service.

The HSIB said that at least seven so-called NHS “never events” should be reclassified because the health service has failed to put in place effective measures to stop them from happening.

They added that NHS England should remove the never event incidents from the list of 15 it requires hospitals to report, due to the fact that they are not “wholly preventable” and the NHS has not properly recognised the systemic risks that mean they keep occurring.

Examples of the errors include a nine-year-old girl who was given a drug by injection that should have been given by mouth, and a 62-year-old man having the wrong hip replaced during surgery.

Other incidents included a 26-year-old man who had a feeding tube incorrectly inserted into his lung rather than his stomach and a woman who had a vaginal swab left inside her following the birth of her first child.

NHS England have stated that there are steps hospitals can take which mean the mistakes should never happen, but HSIB have said that many of the steps are administrative and do not completely take into account the nature of the errors, how they happen, or the environment staff are working in.