Did you know…?

In England, misplacement of a naso- or oro-gastric tube in the pleura or respiratory tract that is not detected before starting a feed, flush or medication administration is considered a ‘Never Event’.[1]

Never events are defined as ‘serious incidents that are wholly preventable because guidance or safety recommendations that provide strong systemic barriers are available at a national level and should have been implicated by all healthcare providers’.[2]


  1. NHS Improvement. Never Events list 2018; 2018. https://improvement.nhs.uk/documents/2899/Never_Events_list_2018_FINAL_v7.pdf. Accessed 15 September 2020.
  2. NHS Improvement. Never Events policy and framework. Revised 2018. https://improvement.nhs.uk/documents/2265/Revised_Never_Events_policy_and_framework_FINAL.pdf. Accessed 15 September 2020.
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