The words to use
- Never event
- A serious incident NHS England treats as wholly preventable because strong national barriers exist. Wrong-tooth extraction has been excluded from the list since April 2021.
- NatSSIPs and LocSSIPs
- National Safety Standards for Invasive Procedures (version 2, January 2023) and the local versions each team writes for its own procedures.
- Swiss cheese model
- James Reason's account of error: harm happens when holes in several layers of defence line up, so fixes should target systems, not just individuals.
- Significant event analysis
- A structured team review of an incident or near miss: what happened, why, what was learned and what was changed.
- Duty of candour
- The legal duty (CQC Regulation 20) for registered providers to tell patients about notifiable safety incidents, apologise and follow up in writing.
