Wrong-site block no longer a Never Event

News Published: 
24 February 2020

Wrong site intra-oral block has been removed from NHS England’s list of Never Events.


The change was recommended last year by a joint NHS England – NHS Improvement working group, and while the definition of the 'wrong site surgery' category of Never Event includes wrong site block for pain relief, ‘local anaesthetic blocks for dental procedures' has been added to the list of exclusions.


However the administration by dental professionals of local anaesthesia in the wrong site will still be classified as a Patient Safety Incident.


NHS Improvement defines Never Events as incidents with “the potential to cause serious patient harm or death” that are “wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and have been implemented by healthcare providers”.


Former FGDP(UK) Dean, Mick Horton, who represented the Faculty on the working group which recommended the exclusion, said:

“I’m delighted that wrong site block has been re-classified as a Patient Safety Incident. It really never should have been classed as a Never Event in the first place, as systemic barriers are not in place to make it wholly preventable, and it is questionable whether it causes serious patient harm.”


The removal leaves wrong site tooth extraction as the only dental Never Event, and practice teams can minimise the risk of this occurring by consulting the related NHS Local Safety Standard for Invasive Procedures toolkit, which was developed with input from FGDP.


The Faculty is also seeking the introduction of an independent, trustworthy and anonymous system for the reporting of all Significant Events in dental practice, including Never Events, to enable the profession to adapt its practice in response to the research and risk analysis such a resource would facilitate.