Misidentification

August 29, 2011

Source: Nursing Times  Volume 107 Issue 25 pp20

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Date of publication: June 2011

Publication type: Journal Article

In a nutshell: Part three of four articles on changes to the Department of Health’s extended ‘never events’ list. Focuses on the use and checking of wristbands to avoid errors arising from wrongly-identified patients. A case study is used to illustrate a ‘nearly never event’ of a patient who almost underwent an invasive procedure intended for another person with the same name, because protocols were not followed correctly.

Length of publication: 1 page

Some important notes: Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library

Acknowledgement: British Nursing Index from NHS Evidence

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Learning from mistakes

June 28, 2011

Source: Nursing Standard  Volume 25, Issue 34 p18

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Date of publication: April 2011

Publication type: Journal article

In a nutshell: The article describes what a never event is, and why the Department of Health expanded the list from 8 to 25 in February 2011.  The main focus of the list is on acute.

Length of publication: 1 page

Some important notes: This article is available in full text to all NHS Staff using Athens, for more information about accessing full text follow this link to find your local NHS Library

Acknowledgement: HMIC


Putting patient safety back at the heart of the NHS

April 4, 2011

Source: Department of Health

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Date of publication: February 2011 

Publication type: News Item

In a nutshell: The Department of Health has increased the list of ‘Never Events’ from 8 to 25.  The list now includes severe scalding; severe harm/death due to misidentifying patients and severe harm/death due to transferring the wrong blood type.  The Never Events List for 2011/2012 can be viewed by clicking here.

Length of publication: 1 web page


‘Never events’ reported to patient safety agency exceed 100 in one year

November 28, 2010

Source: Nursing Times Vol 106 Iss 40

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Date of publication: October 2010

Publication type: Journal Article

In a nutshell: This article looks at the number of ‘never events’ reported to the National Patient Safety Agency, including the 14 new events which willl be added to the existing list of 8.  These include serious disability or death from entrapment in bedrails and serious illness or dealth from insulin overdoses.

Length of publication: 1 webpage

Some important notes:  Please contact your local NHS Library for the full text of the article.  Follow this link to find your local NHS Library.

Acknowledgement: CINAHL


Never Events Framework 2009-10

June 9, 2010

Source:  National Reporting and Learning Service

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Date of publication:  February 2010

Publication type:  Report

In a nutshell:  A list of reports on Never Events, and the processes and guidance recommended.

Length of publication:  1 web page

Acknowledgements:  National Patient Safety Agency