Assessment of the trends of never events across nhs england: a 6-year analysis

Never events (NEs) are serious clinical incidents. Assessing the trends of these incidents over the years will help direct efforts towards specific areas for improvement. The NHS has made significant efforts in this direction by introducing the National Safety Standards for Invasive Procedures (NatSSIPs) in 2015 and updating them in 2023. This study aims to assess the trends of the common themes of NEs and highlight potential solutions in the available literature and NatSSIPs.

A taxonomy development and thematic analysis of the NHS NEs annual reports from 2018 to 2024 to identify the common themes and assess the trends of these incidents.

We identified 2485 NEs, including 1091 wrong surgeries, 561 retained objects, 266 wrong implants, and 198 medication-related NEs. The overall incidents showed a downward trend. Wrong implants showed a declining pattern over the study period, while retained objects and wrong surgery showed a fluctuating curve. Medication NEs levelled out. Analysis of the individual themes showed a decline in the wrong side/site procedure. Wrong skin lesion / biopsy removal has increased recently. Retained vaginal and surgical swabs, as well as guidewires, were the most common retained items. They showed fluctuating curves without clear improvement. Wrong hip implants show a sharp decline after 18-19, followed by fluctuations at lower levels. Wrong-lens incidents remained stable over the years. There was a noticeable decline in incidents of wrong midazolam strength and an upward trend in wrong-route medication administration. NEs related to misplaced nasogastric tubes, falls, and mismatched blood transfusions were stationary without a discernible pattern.

An assessment of the trends of NEs provides a clear picture of the current situation, highlighting areas for improvement and further work. This analysis provides a baseline for assessing the effectiveness of the updated version of NatSSIPs in future work.