WTP8.03 Trends of Common Themes of Never Events in NHS England over 6 years

Background Never Events (NEs) are serious clinical incidents. The NHS has made great efforts to prevent the recurrence of these incidents through the introduction of the National Safety Standards in 2015 and its update in 2023. This study aims to assess the trends of the common themes of NEs. Methods Thematic analysis of the NHS NEs annual reports from 2018 to 2024 (after the last update of NEs List) to identify the common themes and assess the trends of these incidents. Results We identified 2485 NEs, including 1091 wrong-site surgeries, 561 retained objects, 266 wrong implants, and 198 medication-related NEs. Wrong implants showed a downtrend, while retained items and medications NEs had a stationary curve. Among the common themes of Wrong-site surgery, wrong skin lesions and wrong injections have an upward trend. Wrong side/site surgery rates decreased over the study period. Retained vaginal and surgical swabs and guidewires were the common retained items. They showed fluctuating curves without clear improvement. The rate of wrong intrauterine devices slightly declined, while wrong intraocular lenses increased. Misselection of midazolam strength incidents obviously decreased, while wrong-route medication and insulin errors rose. There was a consistent decline of the incidents of unintentional connection to air flowmeter instead of oxygen. NEs related to misplaced nasogastric tubes, falls, mismatch blood transfusions were stationary without discernible pattern. Conclusions Assessment of the trends of NEs draws a clear picture of the current situations and highlight the areas for improvement and further work.