Never Events Learning Hub

Sharing research and practical learning to help NHS theatre teams
reduce and prevent Never Events.

PhD Research

Examining the systemic drivers of surgical errors. Key findings include the need for better "System Resilience" and closing the gap between national policy and theatre workflow.

NatSSIPs 8 Flowchart

PIT Stop Checklist

Enhancing Human Factors

Patient Safety Learning

The Roadmap Ahead

This platform is evolving. Future updates will include an anonymized incident library, video training modules, and a national peer-to-peer forum for Safety Leads.

Lembitz, A. and Clarke, T.J. (2009) ‘Clarifying ‘Never Events’ and introducing ‘always events’’, Patient saf surg, 3, p.26. Doi: 10.1186/1754-9493-3-26.
World Health Organisation (2009a) WHO Surgical safety checklist.
Department of Health (2011a) The “Never Events” list 2011/12.
Shah, J., Fitz-Henry, J. and Vickers, R. (2011) ‘Peri-operative care series’, RCS Advancing surgical standards. Ann R Coll Surg Engl, 93, pp. 501-503.
National Patient Safety Agency (NPSA) (2010), National Patient Safety Alert. Alert 0861. National Patient Safety Agency, London, (2009).
Safe Anaesthesia Liaison Group (SALG) (2021) Stop Before You Block.
NHS England (2012) The Never Events policy framework. An update to the Never Events policy.
NHS England (2014b) Standardise, educate, harmonise: commissioning the condition for safer Surgery. Report of the NHS England Never Event Taskforce.
NHS England (2015b) National Safety Standards for Invasive Procedures.
British Dental Association (BDA) (2021) Wrong tooth extraction removed from never evets list.
NHS Improvement (2021) Never Events list 2018, first published January 2018 (Last updated February 2021).
Haslam, N., Bedforth, N. and Pandit, J. J. (2021) ‘Prep, stop, block’: refreshing ‘stop before you block’ with new national guidance.
National Safety Standards for Invasive Procedures 2 (NatSSIPs) (2023).
Centre for Perioperative Care (2023) The National Safety Standards for Invasive Procedures (NatSSIPs).

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Email Nigel Roberts

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