Occurrence of surgical ‘never events’ unrelated to hospital performance


A comprehensive study published in Anaesthesia has found that the only factor influencing ‘never events’ at individual hospitals is their size.

NHS England defines ’never events’ as “serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented”. These ’never events’ have been shown to happen approximately once in every 16,500 operations, leading to major harm around once in 250,000 operations.


In this NHS-based study, every hospital Trust in England was contacted using Freedom of Information requests, and all responded by providing data. The study authors conclude that “’never events’ are important but rare, apparently random, events, and are the wrong metric to gauge safety within the operating theatre”.


The Anaesthesia study found that 158 English NHS Hospital Trusts reported 742 surgical ’never events’ over a three-year period, encompassing over 3 million operations. Almost 50% of surgical ’never events’ were reported to cause no or minimal harm, and only 7% caused severe harm. There was a small, but insignificant, fall in the number of surgical ’never events’ each year between 2011 and 2013. The rate of surgical ’never events’ seems to be about the same as in the USA.


An average-sized English hospital undertakes around 24,000 operations each year, so based on current rates would be expected to have one-to-two surgical ’never events’ each year. The study found that almost all hospitals had around their expected number of surgical ’never events’ over the three-year period, and that there was no association between the occurrence of ’never events’ and any other measures of hospital safety such as CQC ratings or hospital mortality data (death rates) – only the size of the hospital seemed to matter.


Whilst ’never events’ certainly do continue to occur, and on rare occasions can be catastrophic, they seem to be relatively unusual. When they do occur, the study authors conclude that this does not imply that the hospital or its operating theatres are particularly unsafe.