What is a Never Event?
A Never Event is a type of serious incident that should not happen if the right safety barriers are in place. The idea is that, for a small number of incident types, national guidance tells us how to prevent them, and every organisation providing NHS care should already have implemented that guidance. If one still occurs, it shows that a barrier was missing, was bypassed, or did not work as designed.
The name causes confusion. It does not mean these incidents are impossible, and it does not mean the person closest to the patient was careless. Most Never Events happen to skilled, experienced teams. They happen when checks become routine, when time pressure builds, or when someone notices a problem but does not feel able to stop the process.
What is on the Never Events list?
The current list is the Never Events list 2018, which has been amended since publication. Each item has a precise definition with inclusions and exclusions, so always read the full definition before deciding whether an incident qualifies. The main headings are below.
| Group | Never Event | Plain-language example |
|---|---|---|
| Surgical | Wrong site surgery | An operation, injection or nerve block on the wrong patient, side, digit or site, or the wrong procedure |
| Surgical | Wrong implant or prosthesis | A hip component or intraocular lens that was not the one planned |
| Surgical | Retained foreign object post procedure | A swab, needle, instrument or guidewire left inside the patient, including vaginal swabs after birth |
| Medication | Mis-selection of a strong potassium solution | A concentrated potassium product selected in place of the intended solution |
| Medication | Administration of medication by the wrong route | An oral liquid given intravenously |
| Medication | Overdose of insulin due to abbreviations or incorrect device | 'U' for units misread as a zero, or insulin drawn from a pen into a syringe |
| Medication | Overdose of methotrexate for non-cancer treatment | A weekly dose given daily (applies where electronic prescribing is in use) |
| Medication | Mis-selection of high strength midazolam during conscious sedation | A high-strength product used where a lower strength was intended |
| Mental health | Failure to install functional collapsible shower or curtain rails | Non-collapsible rails in an inpatient mental health setting |
| General | Falls from poorly restricted windows | A patient falling from a window that was not properly restricted |
| General | Chest or neck entrapment in bed rails | A patient trapped between a bed rail and the mattress or frame |
| General | Transfusion or transplantation of ABO-incompatible blood components or organs | The wrong blood group given because of an identification error |
| General | Misplaced naso- or oro-gastric tubes | Feed or medication given through a tube in the lung that was not detected before use |
| General | Scalding of patients | A patient scalded by bath or shower water at an unsafe temperature |
| General | Unintentional connection of a patient requiring oxygen to an air flowmeter | Tubing connected to the medical air outlet instead of oxygen |
The list also includes undetected oesophageal intubation, but this item has been temporarily suspended. Wrong-site surgery and retained foreign objects are consistently among the most frequently reported categories in NHS England's published data, which is one reason surgical and procedural safety receives so much attention.
Is the Never Events framework being replaced?
Yes, but not yet. NHS England consulted on the framework in 2024 and published its findings in September 2025. Most respondents felt the framework was not working well, and many said the label encouraged blame and harmed staff morale. NHS England said its preferred option is to revise the definition and process so that events need not be 'wholly preventable', with a new approach focused on learning, aligned with the Patient Safety Incident Response Framework (PSIRF), and extended to settings such as mental health and primary care.
Whatever the label becomes, the barriers themselves will not disappear. Correct identification, site marking, the surgical safety checklist, counts, tube position checks and safe medicines systems remain the foundation of safe care.
How are Never Events prevented?
Each Never Event has known barriers. For invasive procedures, the National Safety Standards for Invasive Procedures 2 (NatSSIPs 2, 2023), published by the Centre for Perioperative Care, set out the steps that should surround any procedure, wherever it happens. Organisations turn these into local standards, often called LocSSIPs. Understanding what each barrier is for makes it far less likely you will treat it as paperwork.
| Barrier | What good practice looks like | What it prevents |
|---|---|---|
| Specific consent | The procedure and side written in full, never 'L' or 'Rt' | Wrong procedure or side |
| Active identification | The patient states their name and date of birth, checked against wristband, consent and list | Wrong patient |
| Site marking | An indelible mark at the site before the patient enters the anaesthetic room, checked with the patient where possible | Wrong side, digit or site |
| Team brief and surgical safety checklist | Sign in, time out and sign out done aloud with the whole team engaged | Wrong site, missing equipment, missed counts |
| Stop before you block | A pause just before a regional block needle, confirming the mark and side | Wrong-side nerve block |
| Implant check | Type, size and side read aloud against the plan before opening | Wrong implant |
| Counts | Two people counting aloud and recording swabs, sharps and instruments at set points | Retained foreign object |
| Tube position confirmation | Following national and local guidance before anything goes down a nasogastric tube | Feeding into the lung |
| Safe medicines systems | Restricted stock, clear labelling, electronic prescribing safeguards, no abbreviations for units | Wrong drug, strength or route |
Why do Never Events still happen?
If the barriers are well known, the explanation lies in human factors and in how teams work under pressure. In the Swiss cheese model, each barrier has weaknesses. A Never Event happens when several weaknesses line up on the same day.
- Checklist fatigue: the checklist is read by one person while everyone else carries on working, and boxes are ticked without anything being checked.
- Hierarchy: a junior colleague notices something wrong but does not feel able to stop a senior.
- Production pressure: long lists and late starts push teams to shorten checks.
- Changes: patients are reordered, the side is changed, or staff swap mid-procedure without a proper handover or count.
- Confirmation bias: people see what they expect, so a mark made from the list is confirmed against the same wrong list.
- Design: look-alike packaging, abbreviations, and paper records that do not match electronic ones.
- Location: procedures in clinics, wards, emergency departments and delivery rooms may lack the same structured checks as main theatres.
Daniel, an operating department practitioner, asks a patient listed for a right inguinal hernia repair which side is being treated. The patient points to the left groin. The skin mark is on the right. Daniel stops and asks the surgeon to come and check. The clinic letter confirms a left hernia, and the list had been typed incorrectly. The consent, mark and list are corrected, the patient has the right operation, and the near miss is reported so the booking process can be reviewed. Every barrier that caught the error was a person asking a question and being willing to pause.
What should you do if you are involved in a Never Event?
How you respond in the first hours is often what an employer or regulator looks at most closely. Follow your local policy alongside these steps.
- Make the patient safe: If the error is discovered during a procedure, stop and agree a plan with the senior clinicians present. If a retained item is suspected afterwards, arrange imaging and senior review.
- Escalate straight away: Tell the responsible consultant and the senior nurse, midwife or coordinator. Do not wait until the end of the list or shift.
- Preserve evidence: Keep the count board, checklist, consent form, implant stickers and packaging, and any retained item, as your policy requires. Do not tidy away or alter anything.
- Be open with the patient: Tell the patient, or those close to them, what happened, apologise and explain what happens next. This is a professional duty for every registrant, and in England providers also have a statutory duty of candour for notifiable safety incidents. An apology is not an admission of legal liability.
- Document factually: Record what happened, when it was found, who was told and what was done. Never alter earlier entries; mark any additions as late entries with the date and time.
- Report and take part in the review: Complete an incident report. Your organisation will decide on the learning response under PSIRF and handle external reporting.
- Get support and advice: Take part in a debrief and talk to your supervisor or manager. If your regulator contacts you or you are asked for a formal statement, seek advice from your defence organisation, trade union or legal representative first.
How do regulators view a Never Event?
Regulators such as the GMC, NMC and HCPC do not ask whether you have ever made a mistake. They ask whether your fitness to practise is currently impaired, looking at insight, remediation and the risk of repetition. A single incident, handled honestly and followed by genuine learning, does not usually mean a professional is unsafe, although every case is judged on its own facts.
A swab was left in because the count wasn't done properly. It was a very busy shift and we were short-staffed. I will make sure counts are done properly in future.
I placed a swab in the vagina to help see a tear, did not record it on the count board, and did not mention it when I handed over to my colleague. Because it came from a separate pack, the tray count could not detect it. The woman had pain and infection and her trust in us was damaged. I was open with her and apologised. I now announce and record every inserted swab, include it in every handover, and confirm the count with whoever completes the repair. A senior midwife has observed my practice over several months, and I helped add a prompt for inserted swabs to our handover tool.
The stronger reflection names the specific barrier that failed and the writer's part in it, explains why the system did not catch it, acknowledges the impact on the patient, avoids blaming colleagues or staffing, and shows verified, sustained change. Only include learning and supervision that has actually happened.
Learning more about surgical and procedural safety
Whether you work in theatres, maternity, endoscopy, interventional radiology or a ward, it is worth knowing which Never Events relate to your own practice and which barriers you personally own. Read your local LocSSIPs, watch how checks are actually done in your area, and practise speaking up in simulation or team training.
Our course Never Events and Surgical Safety covers the barriers in more depth, explains how human factors allow them to fail, sets out the immediate actions after an incident, and guides you through a structured reflection and remediation plan. It suits professionals building their safety knowledge as well as those who have been involved in an incident and want to show insight to an employer or regulator.
Frequently asked questions
What are the three most common Never Events?
In NHS England's published data, the surgical categories are consistently the most frequently reported: wrong site surgery, retained foreign object post procedure (such as swabs, instruments or guidewires) and wrong implant or prosthesis. Exact numbers vary each year and published figures are often provisional, so check NHS England's latest Never Events data rather than relying on older totals.
Are Never Events still used in the NHS?
Yes, for now. NHS England published consultation findings in September 2025 saying it intends to replace the framework with a new approach aligned with PSIRF. Until that happens, the existing framework remains active, and qualifying incidents are still recorded on the Learn from Patient Safety Events service, responded to under PSIRF, and subject to the duty of candour.
What is an example of a Never Event in nursing?
Examples relevant to nursing include feeding through a nasogastric tube that is in the lung without detecting the misplacement, giving an oral liquid medicine intravenously, an insulin overdose caused by an abbreviation or by drawing insulin from a pen into a syringe, connecting a patient who needs oxygen to an air flowmeter, and scalding a patient with bath or shower water.
Is a near miss a Never Event?
Generally no. A Never Event involves an incident that actually happened to a patient, as defined in the national list. A near miss, such as a wrong-side mark caught before the procedure, should still be reported through your local system because it shows where a barrier was weak. Check your organisation's policy for how near misses are recorded and reviewed.
Will I be referred to my regulator after a Never Event?
Not automatically. Most Never Events are reviewed locally under PSIRF with a focus on system learning. A referral may follow if there are concerns about an individual's competence or honesty. If you are contacted by your regulator, seek advice from your defence organisation, trade union or legal representative before responding, and be open and factual throughout.
Is a Never Event the same as a serious incident?
Not quite. The older Serious Incident Framework has been replaced in England by PSIRF, which asks organisations to plan proportionate learning responses rather than classify incidents by seriousness. Never Events remain a specific category with their own definitions, and organisations respond to them under PSIRF. They are among the incident types where a learning response is expected.
Does the Never Events list apply in Scotland and Wales?
The Never Events list and framework are published by NHS England for NHS-funded care in England. Scotland, Wales and Northern Ireland have their own arrangements for reporting and learning from serious adverse events. The underlying safety barriers, such as the surgical safety checklist and counts, are used across the UK, so check your local and national policy.
Related courses
Never Events and Surgical Safety
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Sources and further reading
- Never Events list 2018. NHS England.
- Never Events framework: 2024 consultation findings. NHS England.
- Patient Safety Incident Response Framework. NHS England.
- National Safety Standards for Invasive Procedures 2 (NatSSIPs 2). Centre for Perioperative Care.
- Openness and honesty when things go wrong: the professional duty of candour. General Medical Council and Nursing and Midwifery Council.
- Regulation 20: Duty of candour. Care Quality Commission.
Practitioner Insight is an independent education provider. It is not affiliated with or endorsed by the GMC, MPTS, NMC, HCPC, GPhC or any NHS organisation, and this information is not legal advice. If you have been referred to a regulator, speak to your defence organisation, trade union or legal representative.
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