Never events: the cultural and systems issues that cannot be addressed by individual action plans.

Despite the term 'never events' these events continue to happen in the NHS. This paper considers the findings from a review of the causes of nine surgical 'never events'; looking at the learning from the investigations to provide 'a window on the system' and considering the multiple issues that need to be addressed to reduce future risk. The paper discusses why many of the causes described in investigation reports cannot be adequately addressed by the action plans that target each individual cause - things are never that simple - instead the causes should be seen as a reflection of the current state of safety within an organization, showing the underlying cultural and systems issues that need to be addressed at a wider level than that of the incident itself. [ABSTRACT FROM AUTHOR]