Finding Solutions to a Never-Ending Problem: Insights From a 10-Year Review of Surgical Never Events in NHS England

Introduction: Surgical never events (NEs) are preventable serious patient safety incidents.Despite the significant resources invested in the prevention of surgical NEs, hundreds of such events are reported annually.This paper explores trends in the types and frequency of surgical NEs reported by NHS England organisations over the preceding 10 years and suggests practical interventions for their prevention.Materials and methods: This study analysed annual NEs data published by NHS England from April 2016 to March 2026 inclusive.Data relating to the frequency of total NEs, surgical NEs, different categories of surgical NEs, and hospital admission statistics were extracted into a Microsoft Excel® workbook (Microsoft Corporation, Redmond, WA, USA).Descriptive statistics and charts were produced using Microsoft Excel® to compare surgical NE counts and rates across the years under review, and the Mann-Kendall test was used to perform trend analysis.Results: Surgical NEs accounted for approximately 80% of the 4,336 NEs reported over the past decade by NHS England organisations.The highest number of surgical NEs occurred during the year ending March 2019.Since the 2019 peak, there has been a statistically significant decline in the number of surgical NEs per hospital admission episode (Mann-Kendall τ = -0.86;p = 0.004; Bonferroni-adjusted p = 0.02; rate of decline: -3.0%/year; 95% CI: -5.7% to -1.9%), although the corresponding fall in the overall incidence of surgical NEs was not statistically significant (τ = -0.21;Bonferroni-adjusted p = 1.000).Conclusion: There has been a downward trend in the number of surgical NEs per hospital admission episode across NHS England organisations since the COVID-19 pandemic.This may be due, in part, to the widespread adoption of surgical safety checklists since the year 2021.To further minimise the occurrence of surgical NEs, it is important to focus on addressing specific incidents, such as wrong site and wrong patient surgery, retained surgical and vaginal swabs, and wrong orthopaedic implants, which account for a disproportionate number of surgical NEs.