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Never Events in General Practice

Acts of omission

  1. A planned referral of a patient, prompted by a clinical suspicion of cancer, is not sent.

Investigations

  1. An abnormal test result is received by a practice but not considered for action, or the considered action is not performed.

Prescribing medication, when known, absolute contraindications exist

  1. Prescribing teratogenic drugs to a patient known to be pregnant.
  2. Prescribing combined oral contraceptive after previous confirmed DVT/PE.
  3. Prescribing oestrogen-only HRT for women with intact uterus.
  4. Prescribing a drug to a patient that has correctly been recorded in the practice system as having previously caused them a severe adverse reaction.

Medication (prescribing, dispensing, administration, monitoring)

  1. Prescribing ‘high risk’ medication without ensuring adequate monitoring took place and results were satisfactory.
  2. Giving the right drug via the wrong route or at the wrong site.
  3. Prescribing immunosuppressives daily rather than weekly (unless initiated by a specialist for a specific clinical condition, eg leukaemia).
  4. Prescribing aspirin for a patient under 12 years old (unless recommended by a specialist for a specific condition, eg Kawasaki’s disease).

Medicolegal and ethical incidents

  1. Physical assault of patients or healthcare workers.
  2. Ignoring a patient’s living will.
  3. A practice team member working while intoxicated.
  4. Losing controlled drugs.

Clinical management

  1. Not referring a patient presenting with and treated for anaphylaxis to secondary care for observation.
  2. Not referring a child suspected to have non accidental injuries urgently.
  3. Performing a cervical smear without visualising the cervical os.

Practice systems

  1. A practice does not have an up-to-date and secure backup of their data.
  2. Medical waste and hazardous substances discarded in an inappropriate manner.
  3. Emergency medical equipment, eg defibrillator, is not in working order, maintained, available or checked regularly.
  4. A needlestick injury due to a failure to dispose of ‘sharps’ in compliance with national guidance and regulations.