Reducing preventable patient harm in ophthalmology: A 12 year analysis of reported never events in the National Health Service in England

Background: Ophthalmology remains one of the highest-volume surgical specialties worldwide, with more than one million procedures performed annually in England alone. Never events (NEs), though rare, are high-impact, preventable incidents, and can have significantly negative consequences on patient outcomes. The National Health Service (NHS) in England provides transparent data regarding the frequency and classification of NEs across all surgical specialties, though long-term trends have not yet been extracted and analysed for ophthalmology. We conducted the first 12-year analysis of the prevalence of ophthalmic NEs in England to identify dominant error patterns, national trends and propose internationally scalable interventions for reducing the incidence of preventable ophthalmic surgical errors.

Methods: A retrospective analysis of all official NHS England Never Events data between March 2013 and April 2025 was assessed, and all events deemed to be specific to the field of ophthalmology were recorded for further data analysis. Annual procedure counts were obtained from Hospital Episode Statistics (HES). Descriptive statistics were calculated, and trend analyses were performed on the data using simple linear regression.

Results: Between March 2013 and April 2025, a total of 4,914 NEs were reported in NHS services across England, 283 (5.76%) of which were specific to ophthalmology. With 9,130,830 ophthalmology procedures performed over the 12-year period, this corresponded to 3.10 NEs per 100,000 procedures. The dominant NE across all years was incorrect intraocular lens (IOL) implantation, with 192 (67.8%) incidences reported in total. Other major NEs included wrong eye intravitreal injection (n = 27, 9.64%), procedure on the incorrect eye (n = 27, 9.64%), and retained ophthalmic items (n = 16, 5.65%). Despite rising national surgical volume, linear regression demonstrated a significant downward trend in annual NE incidence over time (slope = -0.03892 ± 0.008914, p = 0.0014), with 65.6% of the variation explained by year (R2 = 0.6559).

Conclusions: Ophthalmology never events in England have fallen markedly over the past 12-years, reflecting a substantial national patient safety success. However, persistence of specific error types highlights key areas for improved safety initiatives, including more stringent pathways and safeguards for IOL verification, and surgical and intravitreal injection sites. Given the high surgical volume in ophthalmology and the irreversibility of many patient errors, these findings provide a critical national benchmark and offer internationally transferable strategies to strengthen ophthalmic surgical safety worldwide.