September 17, 2019

‘Never Events’ – when injury is wholly preventable, but happens anyway

'Never Events' are defined as serious incidents (with the potential to cause serious patient harm or death) that are wholly preventable, because guidance or safety recommendations which provide strong systemic protective barriers are available at a national level, and should have been implemented by all healthcare providers.

NHS Improvement’s list of 'Never Events' was revised in 2018. It includes a wide range of avoidable events, ranging from wrong site surgery to neck entrapment in bed rails. Also in 2018 a report was published by the Care Quality Commission in relation to 'Never Events', entitled “NHS Safety Culture and the Need for Transformation”, which concluded that patient safety in this context could be further improved.

Examples of ‘Never Events’

The list of 'Never Events' is divided into four broad categories:

  • Surgical – such as wrong-site surgery, wrong implant/prosthesis and retained foreign object post-procedure.
  • Medication - such as overdose of methotrexate for non-cancer treatment, and mis-selection of high strength midazolam during conscious sedation, as well as more generic examples such as administration of medication by the wrong route.
  • Mental health – this category is focused on the enabling of patient suicide by the failure to install or maintain collapsible curtain or shower rails.
  • General – this category is fairly eclectic, as might be expected, including falls from poorly restricted windows, chest or neck entrapment in bed rails, misplaced naso-gastric or oro-gastric tubes, and scalding of patients.

What is the purpose of classing certain events as ‘Never Events’?

By definition, a ‘Never Event’ must be an event which has occurred on a number of previous occasions, broadly by the same mechanism, and where steps have been taken on a systemic basis to guard against its recurrence.

Hence, when such events do reoccur, it is important that the Never Events Policy and framework require honesty and accountability and learning from the relevant healthcare provider, to avoid further recurrence.

What happens after a ‘Never Event’ occurs?

It is essential that Never Events are investigated fully under the Serious Incident framework, and are reported both to the Strategic Executive Information System (StEIS) and to the National Reporting and Learning System (NRLS).

Full analysis of a ‘Never Event’ must be carried out using a systems-based investigation method (such as a Root Cause Analysis) to understand how and why it occurred. It is then mandatory to implement actions which measurably reduce the risk of recurrence.

Is this system working?

Unfortunately it is certainly the case that certain Never Events are continuing to recur with alarming regularity, and we see this frequently as clinical negligence lawyers.

The CQC, in its report referenced earlier, concluded that the current patient safety landscape was confused, with many different organisations taking responsibility for safety, and Trusts complaining that they receive multiple messages on certain issues.

More significantly perhaps, in this context, the CQC concluded that there was a lack of learning from incidents at a local and national level which was hampering significant progress. Further conclusions were that:

  • varying cultures between different Trusts meant that information was not always shared;
  • Trusts were not incentivised to collaborate to learn from incidents;
  • better technology was needed to enable reporting and learning to take place across the system. 

Clearly the concept of Never Events is a useful one, and it is increasing accountability among healthcare providers. Nonetheless there remain systemic issues which are not conducive to a “black-box” learning culture, and NHS Improvement will need to reflect and continue to act upon the CQC’s recommendations if further significant advances in patient safety are to be made.

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