Journal of Surgical Simulation 2017; 4: A: 7 - 7

Published: 19 January 2017


Oral presentation

Special Issue: Engineered solutions to never events and novel simulation methods

Maryanne Mariyaselvam and Mark Blunt
Corresponding author: Maryanne Mariyaselvam, Clinical Research Fellow, Cambridge University Hospitals, Cambridge, UK. Email:


Never events are preventable errors, which should not occur in healthcare systems. However, despite a root cause analysis and instigation of re-education, re-training, introduction of checklists or changing policy in hospitals, data reported to NHS England continues to show recurrence of never events.1 Never events are rare errors, with an incidence of 1:several thousand. Humans are fallible and prone to mistakes. Therefore, it is impossible for humans to remember every error possibility, in every situation, every time. Hence the energy and transport industries use engineered solutions, designed to minimise human error by redesigning systems to prevent obvious mistakes.

Once these systems have been designed, it is important to test their efficacy with robust and efficient methodology. However, for rare errors, occurring in 1:several thousand procedures, this may be difficult to test. A novel test methodology used in the energy and transport industries is disaster simulation testing.2 During the simulation study, the participant, without their knowledge, is forced through error pathways to determine whether they make the error of causing the never event, and to determine whether the novel intervention prevents the error at the final stage. This methodology has been utilised to test two engineered solutions to prevent never events with successful results.


1. NHS England National Learning and Reporting Database.

2. Donahue AK, Tuohy R V. Lessons we don’t learn: a study of the lessons of disasters, why we repeat them, and how we can learn them. Homeland Security Affairs 2006;II(2):1-28.


safety engineering; never events; engineered solutions; healthcare

Additional Information

This presentation was given at the 6th Annual Homerton Simulation Conference: Safety Engineering and Simulation in Healthcare, Homerton University Hospital, London, UK, on 1 December 2016.

Conflicts of interest: Dr Mariyaselvam and Dr Blunt are developing safety innovations through the NHS Innovation Agency, the Innovation Accelerator Programme and the NHS Clinical Entrepreneur Programme or directly with industry. None of the developed technologies have been discussed in this abstract.