for Invasive Procedures (NatSSIPs)

OFFICIAL
3.2 The development of the NatSSIPs
Surgical Never Events and patient safety
The concept of ‘Never Events’ was introduced into the UK in 2009, with a list of eight
adverse patient safety events and a definition of “serious, largely preventable patient
safety incidents that should not occur if the available preventative measures have
been implemented”. Amongst the original eight Never Events were two of the three
core surgical Never Events: wrong site surgery and retained instrument postoperation.
The 2010 Never Events Framework extended the scope of the latter
Never Event to include retained swabs and throat packs. A 2012 document entitled
“The Never Events policy framework” added a third core surgical Never Event
(wrong implant/prosthesis) and redefined the retained instrument event as
“retained foreign object post-operation”.
It was anticipated that the mandatory introduction of the WHO Surgical Safety
Checklist in 2010 and the refinement of the three surgical Never Events would lead to
a significant reduction in their incidence in the NHS in England. However, a marked
decrease in these three Never Events was not seen and, in 2013, NHS England’s
Surgical Services Patient Safety Expert Group commissioned a Surgical Never
Events Taskforce to examine the reasons for the persistence of these patient safety
incidents, and to produce a report making recommendations on how their occurrence
could be minimised.
The report, published in 2014 1 , advised the development of high-level national
standards of operating department practice that would support all providers of NHSfunded
care to develop and maintain their own, more detailed, standardised local
procedures. The group tasked with creating these standards have named these
National Safety Standards for Invasive Procedures (NatSSIPs) and Local Safety
Standards for Invasive Procedures (LocSSIPs).
This document launches the concept of national and local safety standards, and sets
out their rationale and place in the continuous improvement of the safety of care for
patients undergoing invasive procedures. The aims of the creation of LocSSIPs are
the standardisation and harmonisation of clinical practice throughout the NHS and
the development of consistency in education, commissioning and regulation.
Most provider organisations will already have local policies for invasive procedures
that can be used as a basis for the creation of LocSSIPs that are compliant with the
NatSSIPs published in this document.
Never Events and the Duty of Candour – new definitions, new guidance, new
legislation
NHS England’s Never Events Framework is modified and updated regularly to reflect
feedback from organisations reporting and investigating Never Events. The latest
update, published in March 2015 3 , details the 14 current Never Events and provides
the following definition:
3 http://www.england.nhs.uk/ourwork/patientsafety/never-events/
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