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Sir, we are writing to inform colleagues of the recent update to the NHS Never Events list. According to NHS Improvement, Never Events are defined as 'serious incidents that are entirely preventable because guidance or safety recommendations providing strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers'.1
A list of eight core Never Events were originally implemented in 2009 by the National Patient Safety Agency. The most recent revision of the Never Events list, in January 2018, categorises incidents as those related to 'Surgical', 'Medication', Mental Health' and 'General' domains.
Pertinent to dentistry, the latest update includes the incorrect extraction of primary teeth as a wrong site surgical Never Event. It is, however, a matter of some contention that the incorrect extraction of primary teeth is only classified as a Never Event if the extractions are completed under general anaesthesia. The justification provided for this is that 'the extraction of primary (milk) teeth is extremely unlikely to result in severe harm/death unless it is done under a general anaesthetic when the potential risks of anaesthesia could apply.'2
For interest, also relevant to dentistry is the previous inclusion on the list of wrong site pain relief blocks, biopsies, implants that differ from that specified in the procedural plan, and teeth extracted in error that are immediately reimplanted. Notably, the list excludes wrong site surgery due to incorrect referral letters; of particular relevance perhaps to those who frequently request the extraction of teeth for orthodontic purposes.
References
NHS Improvement. Revised Never Events policy and framework and Never Events list 2018. January 2018. Available at: https://improvement.nhs.uk/resources/never-events-policy-and-framework/#h2-revised-never-events-policy-and-framework-and-never-events-list-2018 (accessed April 2018).
NHS Improvement. Previous versions of the Never Events policy and framework and Never Events list. January 2018. Available at: https://improvement.nhs.uk/resources/never-events-policy-and-framework/#h2-previous-versions-of-the-never-events-policy-and-framework-and-never-events-list (accessed April 2018).
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McKernon, S., Gartshore, L. Never events: Recent update. Br Dent J 224, 759 (2018). https://doi.org/10.1038/sj.bdj.2018.403
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DOI: https://doi.org/10.1038/sj.bdj.2018.403
