This course explains what Never Events are, why wrong-site surgery, retained items and similar incidents still happen despite strong safety barriers, and what you must do if you are involved in one. It shows how regulators judge insight and remediation, and ends with a guided reflection and a remediation plan you can place in your portfolio.
What you will learn
- Explain the concept of a Never Event and give examples relevant to surgical, procedural and maternity practice.
- Describe the main barriers that prevent wrong-site procedures, wrong implants and retained foreign objects, including site marking, counts and the safety checklist.
- Analyse how human factors, team culture and system design allow these barriers to fail.
- Take the correct immediate actions after a Never Event, including patient safety, escalation, documentation, reporting and the duty of candour.
- Write a structured reflection and an evidence-based remediation plan that shows insight to an employer or regulator.
Course content
- What Never Events are and why they matter (4 min)
- The barriers: how wrong-site and wrong-implant events are prevented (4 min)
- Preventing retained foreign objects (3 min)
- Why Never Events still happen (2 min)
- Immediate actions after a Never Event (2 min)
- What regulators expect: insight and remediation (2 min)
- Case study: a weak and a strong reflection (3 min)
- Building your remediation plan (1 min)
- Knowledge check (10 questions, 10 min)
- Guided reflection (15 min)
Standards and guidance covered
- GMC: Good Medical Practice (2024), including the duties on patient safety, raising concerns and openness when things go wrong
- NMC: The Code (2015, updated 2018), including the sections on preserving safety, record keeping and being open and candid
- GMC and NMC: Openness and honesty when things go wrong: the professional duty of candour
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 20: the statutory duty of candour for registered providers in England
- National Safety Standards for Invasive Procedures 2 (NatSSIPs 2, 2023), Centre for Perioperative Care
- NHS England: Patient Safety Incident Response Framework (PSIRF)
- Royal College of Surgeons of England: Good Surgical Practice
Certificate
Courses are free to study. When you pass the knowledge check (80%) and complete your reflection, you can buy a verified certificate showing your CPD time, with a unique ID and QR code that anyone can check on our verification page.
Study free at your own pace on any device.
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.