Cyclical Learning

Never Events should never be learned from in isolation

Too often, serious incidents are investigated within a single organisation, with lessons remaining local rather than being shared more widely across the system. This limits the opportunity for other teams and organisations to review their own safeguards before similar harm occurs.

The purpose of this community is to change that.

Through the safe and constructive sharing of Never Events, PSII themes, near misses and practical learning points, we support cyclical learning across organisations so that one incident can strengthen many systems, not just one.

Shared learning since October 2025

11 Never Event / PSII learning shares
5 newly shared incidents from one NHS Trust
3 wrong site surgery incidents
2 retained foreign object incidents

Why cyclical learning matters

Every shared incident creates an opportunity for others to:

review local policies and governance arrangements
revisit standard operating procedures (SOPs)
assess the reliability of checklists and safety prompts
consider human factors and environmental pressures
test compliance with NatSSIPs and LocSSIPs
strengthen team communication and escalation processes
improve audit, assurance and observational practice

This is the principle of cyclical learning: not simply responding after harm has occurred, but using the experience of others to proactively challenge and improve local systems before recurrence happens elsewhere.

Latest shared learning

A single NHS Trust has recently shared a further five Never Events with the group:

3 wrong site surgery incidents
2 retained foreign object incidents

This brings the total number of Never Event and PSII learning shares since October to eleven.

Each shared event is an opportunity for organisations across the network to reflect on current practice and ask important questions:

• Are our existing controls genuinely reliable?
• Are our checklists being used as intended, or simply completed?
• Are local SOPs aligned with real world theatre practice?
• Are there known vulnerabilities in team communication, escalation or site verification?
• Are we confident that assurance processes would identify drift before harm occurs?

A unique patient safety community

To our knowledge, this is the only group specifically established to enable shared cyclical learning from Never Events and related serious patient safety incidents across organisations.

That matters because meaningful prevention requires more than local investigation. It requires openness, reflection, shared patterns, and the willingness to learn collectively.

Help strengthen the learning network

If your organisation has learning from a Never Event, PSII, near miss, or significant safety intervention that could benefit others, we encourage you to share it with the group.

By sharing openly, responsibly and constructively, we can reduce recurrence, strengthen perioperative safety systems, and improve patient care across the wider NHS.

Please keep sharing. Together, we can turn isolated incidents into system wide learning.

Interested in taking part?

Please complete the attached NE Patient Safety Incident Form, emailing it to me at nigel.roberts1@stockport.nhs.uk if you are interested in joining a community that is dedicated to improving and optimising patient care by reducing intraoperative patient injury through cyclical learning.