Never Events

• Never events are the "kind of mistake that should never happen" in the field of medical treatment. Definition = "Serious incidents that are wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level & should have been implemented by all healthcare providers."
• NatSSIPs (National Safety Standards for Invasive Procedures) and LocSSIPs (Local Safety Standards for Invasive Procedures) aim to:

  • Reduce patient safety incidents
  • Improve delivery of safe care during invasive procedures
  • Improve education and training
• Never events examples:

  • Surgical
  • Wrong site surgery
  • Wrong implant or prosthesis
  • Retained foreign object post-procedure
  • Medication
  • Mis-selection of a strong potassium-containing solution
  • Administration of medication by the wrong route
  • Overdose of insulin due to abbreviations or incorrect device
  • Overdose of Methotrexate for non-cancer treatment
  • Mis-selection of high strength midazolam during conscious sedation
• Never events examples:

  • Mental health
  • Failure to install functional collapsible shower or curtain rails
  • General
  • Falls from poorly restricted windows
  • Chest or neck entrapment in bed rails
  • Transfusion or transplantation of ABO incompatible blood components or organs
  • Misplaced naso or oro-gastric tubes
  • Scalding of patients
  • Unintentional connection of a patient requiring oxygen to an air flowmeter
  • Undetected oesophageal intubation - TEMPORARILY SUSPENDED AS A NEVER EVENT
• Recent never event exclusions:

  • Removal of incorrect primary tooth (unless under GA)
  • Wrong site block - for pain relief (IDB): removed July 2019
  • Incorrect adult tooth extraction: removed April 2021
• "Costs" of a patient safety incident:

  • Several types of "cost"
  • To the pt
  • Physical harm
  • Psychological/emotional
  • To the clinician
  • Stress/anxiety
  • To the trust
  • Reputational
• S.T.O.P. before you block is an example of a LocSSIP (Local Safety Standards for Invasive Procedure).
• S.T.O.P. before you block:

  • Must be completed before supervisor is called
  • Correct local anaesthetic prescription in the notes
  • With details of: drug, dose, technique to be used
  • The pre-needle documentation must be completed in full
  • Including:
  • Tooth in palmer notation
  • Description of tooth e.g. upper right first molar
  • The supervisor will then check and sign this information off before you are able to deliver local anaesthetic
• Local anaesthetic delivery:

  1. Marked bib
  2. Witness watch delivery of LA in the correct site
  3. STOP and agree
  4. Witness documents
• Pre-extraction:

  • Whiteboard must be completed with:
  • Pt's name
  • Pt's date of birth
  • Tooth in palmer notation
  • Description of tooth e.g. upper right first molar
  • Confirm treatment plan with patient and document 'verbal consent given for XLA...' in patient's notes
  • Pre-needle timeout stamp as it is included in 'Time out for dental extractions form'
• During extraction:

  • Patient identifies correct tooth - POINT
  • Student identifies correct tooth for extraction - COUNT
  • Place elevator or forceps on the tooth then STOP
  • Witness/clinical supervisor and student AGREE correct tooth prior to proceeding to extract
• Any break in procedure:

  • 3 Rs
  • Reposition
  • Recheck with direct visualisation
  • Reaffirm with direct visualisation of tooth by supervisor if student, or checklist coordinator, if staff
• Why to use procedureal guidance:

  • To meet national safety standards
  • Direct result of never events occurring within the directorate and the results of their investigation
  • Attempts to prevent likelihood of patient safety incidents
• What to do if a never event occurs:

  • Inform your clinical supervisor immediately
  • Inform patient, apologise & act professionally
  • Manage patient care
  • Once patient care has been managed, your clinical supervisor will
  • Submit a datix form
  • Send an email to:
  • Lead clinician for the department
  • Clinical governance lead
  • Directorate manager
  • Clinical director
  • Consultant responsible for pt's care
• Duty of candour:

  • Openness and Honesty when things go wrong
  • Encouraging a learning culture by reporting errors
  • No blame culture