Was this incident a never event? (Yes, No, Unsure)

Incidents are considered to be never events if:

• The incident either resulted in severe harm or death or had the potential to cause severe harm or death.
• There is evidence that the never event has occurred in the past and is a known source of risk (for example through reports to the National Reporting and Learning System or other serious incident reporting system).
• There is existing national guidance or safety recommendations, which if followed, would have prevented the incident from occurring.
• Occurrence of the never event can be easily identified, defined and measured on an on-going basis.

The full 'never events' 2012/13 list for reference is:

1. wrong site surgery
2. wrong implant/prosthesis
3. retained foreign object post-operation
4. wrongly prepared high-risk injectable medication
5. maladministration of potassium-containing solutions
6. wrong route administration of chemotherapy
7. wrong route administration of oral/enteral treatment
8. intravenous administration of epidural medication
9. maladministration of Insulin
10. overdose of midazolam during conscious sedation
11. opioid overdose of an opioid-naïve patient
12. inappropriate administration of daily oral methotrexate
13. suicide using non-collapsible rails
14. escape of a transferred prisoner
15. falls from unrestricted windows
16. entrapment in bedrails
17. transfusion of ABO-incompatible blood components
18. transplantation of ABO-incompatible organs as a result of error
19. misplaced naso- or oro-gastric tubes
20. wrong gas administered
21. failure to monitor and respond to oxygen saturation
22. air embolism
23. misidentification of patients
24. severe scalding of patients
25. maternal death due to post partum haemorrhage