By John Tingle
In tort law we have a very well-known Latin phrase, ‘Res Ipsa Loquitur’ (the thing speaks for itself). An inference of negligence can be raised by the events that occurred. In the National Health Service (NHS) in England there is a similar concept,‘the Never Event’. The Never Event concept is a USA import into the NHS and was introduced from April 2009. The list of what is to be regarded as a Never Event has been revised over the years in the NHS and is currently set out by NHS Improvement.
Never events include, wrong site surgery, wrong implant/prosthesis, retained foreign object post procedure, mis-selection of a strong potassium solution, administration of medication by the wrong route and so on. Never Events are defined in NHS policy documentation as:
“…patient safety incidents that are wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and have been implemented by healthcare providers. Each Never Event type has the potential to cause serious patient harm or death. However, serious harm or death does not need to have happened as a result of a specific incident for that incident to be categorised as a Never Event.” (p.6)
Never Events should not be happening to the extent that they are in England. The Secretary of State for Health and Social Care, Jeremy Hunt said last year that ’Never Events’, are not really falling in number – more than 1,000 in the last 4 years. After a consultation with stakeholders the Department of Health have produced a new, Never Events policy and framework.One fundamental change has been the abandonment of the financial penalties that can be imposed on hospitals (Trusts) by commissioners of care if a Never Event results. Imposing fines could be viewed as reinforcing the perception of a blame culture. A more proactive approach is needed to avoid the ‘name and shame’ culture that encourages the punitive approach.
Recent NHS Never Event Figures
Provisional publication of Never Events reported as occurring between 1 April and 30 November 2017.There were reported 139 Never Events in wrong site. In one case ovaries removed in error during a hysterectomy when plan was to conserve them.
- 21 reports of wrong route administration of medication.
- 46 reports of wrong implant/prosthesis.
- 3 reports of wrong blood transfused.
- 88 reports of retained foreign object post procedure, and these included:
- Guide wire
- Femoral line
- Screw from instrumentation
- Small piece of metal
- Specimen retrieval bag.
A Shocking List of Errors
This is a shocking list of patient safety errors by any account. Reading all the above, the ovaries removed in error during a hysterectomy when plan was to conserve them is particularly devastating along with the wrong blood being transfused.
In total 332 Never Events are reported during this period. Numbers are subject to change as local investigations are completed.
Never Events are rare occurrences but the figures show that they are stubbornly prevalent and it will take some fresh patient safety policy making and thinking to reduce them. We accept we cannot have an error free health care environment as nobody is infallible but we can try to manage our patient safety system better and hopefully the revised NHS Never Events policy will produce reductions.