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Core list of Never Events

The core list continues to have a focus on acute care. The NPSA is continuing  to work with stakeholders to extend the core list to include incidents from a wider range of care settings.


The core list for 2009/10 and 2010/11 (changes to the detail of the core Never Events for 2010/11 are highlighted in the individual Event description):


  1. Wrong site surgery

  2. Retained instrument post-operation

  3. Wrong route administration of chemotherapy

  4. Misplaced naso or orogastric tube not detected prior to use

  5. Inpatient suicide using non-collapsible rails

  6. Escape from within the secure perimeter of medium or high secure mental health services by patients who are transferred prisoners

  7. In-hospital maternal death from post-partum haemorrhage after elective caesarean section

  8. Intravenous administration of mis-selected concentrated potassium chloride


The criteria used to create the core list

These criteria should be used if PCTs intend to identify additional locally defined Never Events:


  • The Never Event may or does result in severe harm or death to patients or the public

  • There is evidence that the Never Event has occurred in the past, that it is a known source of risk (data sources: Reporting and Learning System and other Serious and Untoward Incident reporting systems)

  • There is existing national guidance and/or national safety recommendations on how the Never Event can be prevented, along with support for implementation.

  • The Never Event is preventable if the national guidance and/or national safety recommendations are implemented

  • Occurrence of the Never Event can be easily identified, defined and measured on an ongoing basis