The National Health Service (NHS) in England has extended the list of “never events” from eight events to 25. Never events are serious, preventable patient safety incidents that should never occur. Currently, primary care trusts (PCTs) are required to monitor the occurrence of never events and publicly report them to the NHS National Patient Safety Agency, which publishes an annual report of never events in England. The NHS National Patient Safety Agency introduced the never events policy in April 2009, following a recommendation in Lord Darzi’s 2008 NHS Next Stage Review.
The expanded list was developed by the NHS in consultation with health professionals, the Royal Colleges, and the public. New events added to the list include severe harm or death due to misidentification of patients, harm due to blood transfusion or organ transplantation errors, prescription drug errors, and severe scalding. The NHS has also introduced a financial penalty; when never events do occur, commissioners (PCTs at present) will be able to withhold payment to NHS providers who delivered care associated with that never event. Although the Department of Health did not detail the specific mechanisms by which this financial disincentive would work, it recommended that local commissioners and providers agree on a cost recovery process, such as setting a cap on payment, when drawing up contracts for services. The full list of never events can be found on the NHS website at http://www.dh.gov.uk/en/MediaCentre/DH_124579.