Four “never events” recorded at Sheffield hospitals including 'wrong site' surgeries

A report has revealed that four serious mistakes known as ‘never events’ took place at Sheffield Teaching Hospitals NHS Foundation Trust last year.

‘Never events’ are serious, largely preventable safety incidents that should not occur if the correct measures are taken.

There are 15 types, which include surgery performed on the wrong site or items such as swabs being left inside a patient.

Sheffield Teaching Hospital NHS Trust’s recent quality report states that two of the four ‘never events’ recorded between April 2023 and March 2024 were wrong site surgeries.

A third incident is described as ‘wrong implant/prosthesis’, and the last as ‘selection of strong potassium solution’.

NHS England describes the latter as “mis-selection”, when a patient is intravenously given the solution rather than the intended medication.

The report does not give specific details, but the Trust said there was “either no or low harm” caused to the patients involved in each incident.

Dr Jennifer Hill,  Chief Medical Officer, Sheffield Teaching Hospitals NHS Foundation Trust said: “We care for over 2 million patients each year and carry out circa 50,000 procedures. 

“We take patient safety extremely seriously and strive not to have any never events. We halved the number of never events last year but regrettably there were still four incidents and we are very sorry they happened.”

The process of categorising never events is not about apportioning blame but to learn from what took place, according to NHS England.

Dr Hill added: “Whenever there is an incident caused by an error, and regardless of the extent of the impact on the patient, it is thoroughly reviewed and learning shared, or processes changed to ensure the chances of it happening again are minimised. We also share the learning with the patient involved.

“One example, in operating theatres, where we try to prevent never events, is that we complete a safety checklist before procedures take place to check critical information relevant to the operation and patient.”

In 2022/23, there were eight ‘never events’ at the Trust.

Provisional data from NHS England does not report any ‘never events’ happening at Sheffield Teaching Hospitals since April 2024.