This document provides an overview of the Never Events reported to the NPSA by NHS organisations in England from 1 April 2009 to 31 March 2010. It describes how the objectives of the Never Event policy have been met, the number of Never Events reported to the NPSA, and the learning at national level. It highlights how commissioners and providers are using the policy to promote patient safety.
Never Events are patient safety incidents that are preventable because:
• there is guidance that explains what the care or treatment should be;
• there is guidance to explain how risks and harm can be prevented;
• there has been adequate notice and support to put systems in place to prevent them from happening.