PHIN publishes data on serious patient safety incidents known as Never Events. This article explains where this information comes from, how to find it on our website, and how it can help you ask informed questions when choosing a private hospital or discussing care with your consultant.

What are Never Events?

Never Events are serious, but preventable incidents where a patient has been put at an unnecessary risk. Hospitals can’t stop patients coming to harm in every case, but Never Events shouldn’t happen if the right processes are in place.

Hospitals have a legal requirement to report these incidents, even if they don’t lead to a patient being harmed. This will help ensure that they aren’t repeated with more serious consequences another time.

There are three categories of Never Events:

• Surgical Never Events include incidents which take place during surgery, such as the surgeon operating on the wrong part of the body
• Medication Never Events are where patients have been administered the wrong type or dose of a medication, or the way the medication was administered in the wrong way
• General Never Events are other incidents which include health and safety incidents, such as a patient becoming trapped in a hospital bed.

It is important for hospitals to document and learn from Never Events to ensure that their processes are the best they can be, preventing possible future events. Never Events for privately funded patients must be notified to PHIN.

How are Never Event measures published?

The measures are published on our website at hospital site level.

We only publish Never Event information where we can confirm that it relates to private patients. Where this is not possible, we will still investigate the event in collaboration with the providers to which they relate.

The Never Event data can be viewed by going to a hospital profile (using the search tool on the homepage or top of every page) and scrolling down to ‘Incident reporting’ and clicking on ‘View latest report overview’:

Once you click on the link to view the overview, Never Events will be one of the incidents reported.

If there have been any events reported, then the website shows the number and also the type of Never Event.

If a Never event has occurred, this does not mean that the hospital is unsafe. It can reflect the fact that they are open about their mistakes and keen to learn and avoid any future issues. It is worth discussing the Never event with your consultant or healthcare team if you have concerns.

For those who would like to know more about Never Events, we also publish an Excel datasheet in the data section of our website.

Click on the Never Events datasheet link and you can download the latest available data, or previous datasheets.

The spreadsheet includes information on:

• Never Events by Event Type
• Never Events by Month
• Never Events by Site

Using this information you can do things like compare the number of Never Events at different site.

Why should I be interested in Never Event information?

If a Never Event has occurred, this does not mean that the hospital is unsafe. It can reflect the fact that they are open about their mistakes and keen to learn and avoid any future issues. It is worth discussing the Never Event with your consultant or healthcare team if you have concerns.

Currently PHIN only publishes counts of Never Events over a recent 12-month period.