Revised Never Events policy and framework

The revised Never Events policy and framework and updated Never Events list was published by NHS England last week. There are three new Never Events, all of which are relevant to anaesthesia, intensive care and pain medicine:

  • Unintentional connection of a patient requiring oxygen to an air flowmeter: this applies when a patient who requires oxygen is connected to an air flowmeter when the intention was to connect them to an oxygen flowmeter
  • Undetected oesophageal intubation: ventilation of a patient following oesophageal intubation instead of the intended tracheal intubation, which is not identified because capnography is not used or capnography readings indicating the need for tracheal intubation are not acted on
  • Wrong side chronic pain block: this has been added to the list of Never Events.

The College will continue to monitor the Never Events policy and framework, and would encourage NHS trusts/boards and staff to take note of the recommendations.

The Never Events framework and the Serious Incidents Framework will be merged later this year. The Care Quality Commission’s Thematic Review of Never Events commissioned by the Secretary of State for Health and Social Care is scheduled for publication in October 2018.

24 January 2018