Never Events
summary
Adopts the NHS definition of a Never Event (4 criteria: wholly preventable, serious harm potential, past occurrence, easily recognized) and shows how to make some incidents impossible: switches nginx localhost TCP links causing ephemeral port exhaustion to UNIX domain sockets to eliminate the limit; enforces terraform change review via plan + Review Board to prevent "apply" wiping environments. Cites numbers: 424 NHS Never Events in a year, 4.7M surgeries with 178 wrong-site cases, wrong-site surgery = 42%, and a 12‑foot SFO near‑miss.
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chapters (9)
- 0:00Intro
- 1:24History of the NHS
- 4:57NHS Serious Incident Framework
- 8:03Systemic Protective Barriers
- 15:18Never Event Criteria
- 16:59NHS Never Events List 2015/16
- 21:02Wrong Site Surgery
- 30:21Retained Foreign Object Post-Procedure
- 37:55Serious Incident Management Process
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