Never Events

Distress Caused by Distraction

“Never Events” are very serious, but very preventable patient safety incidents that should not occur if the relevant measures have been put in place.

The term “Never Event” was coined in 2001 by Ken Kizer, former CEO of the US National Quality Forum.  He used it to refer to serious errors (such as wrong site surgery) that should never occur, not least because it was already known how to prevent them.

The NHS in England went on to adopt the concept in April 2009 following Lord Darzi’s report High Quality Care for All (DH, 2008).  While surgical 'never events' occur in only a tiny fraction of the total number of operations (around 1 per 20,000 operations, or 0.005%) there are around 500 cases per year in the UK. That is 500 events in which patients suffer harm, need extra care, experience bewilderment and anxiety, and lose trust in their care providers; 500 events that have serious consequences for staff including emotional turmoil, loss of confidence and capability, and impact on their employment; and 500 events that require providers to investigate, report, and face financial penalties.

This is where the Ten Thousand Feet Initiative can radically change the Never Event statistics for the better.  

Everyone in theatre has control of the environment and are confident in calling “10,000 Feet” if at any point they feel that noise and distractions are impeding on the care of the patient.

 Ten Thousand Feet will put patients and their families at ease even before the need for surgery arises. To be safe in the knowledge that the entire operating team is capable of working together without judgement, with complete and total focus on the patient from theatre entry to theatre exit. 

Never Events in the Press

Never Events Coverage



Medical blunders at hospital trust include surgery on the wrong body part


Man mistakenly circumcised and wrong patient operated on among errors made by Leicester's hospitals


Bosses apologise over hospital errors


Hundreds of patients suffer due to NHS errors


NHS Blunders Saw 621 Patients With Wrong Body Parts Amputated, Surgical Tools Left Inside Them, And Other 'Never Events'