Regular reviews on Never Events
The NHS has a list of 15 events that should technically never happen. The most common example is ‘wrong site surgery,’ like operating on the wrong patient or body part.
NHS England describe never events 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.”
However, they used to describe never events as “largely preventable”, but in 2018 they updated this to” wholly preventable.” They also strengthened the definition of preventative measures. It is this new terminology that appears to be leading to HSIB now recommending the reclassification of some of the never events.
Why did the HSIB review never events?
NHS England regularly review and report on never events to improve patient safety and reduce the number of further incidences. However, this is not necessarily the case. In fact, wrong site surgery has gradually increased over the years with little improvement in other surgical incidents.
The HSIB investigated the categories that accounted for over 96% of Never Events in 2018/2019:
- Wrong site surgery
- Retained foreign object post procedure
- Wrong implant/prosthesis
- Unintentional connection of a patient requiring oxygen to an air flowmeter
- Misplaced naso or oro – gastric tubes
- Overdose of insulin due to abbreviations or incorrect device
- Administration of medication by wrong route.
If you would like more information about these and the other categories please read our section about claiming compensation for NHS never events.
The HSIB investigated some examples of never events, looking at all the contributory factors. They call out many themes that impact treatment, including:
- Time pressures can lead to humans making mental short cuts in complex situations
- Patient condition and behaviour
- Unfamiliarity and familiarity with tasks might lead to misinformation or lack of concentration
- Fatigue and stress
- The physical environment; such as lighting, layout or noise
- Accessibility or design of tools and equipment may lead to adaptation or confusion over the correct use
- Varied cultures and values across the NHS
- The rolling out and implementation of staff training and initiatives nationally
Lack of systemic barriers
In 2018 NHS England updated the framework and developed safety checks to help healthcare providers working in unfamiliar environments. Also reiterating the importance of the safety checks rather than them being just a mandated activity. It states that “as all human action is vulnerable to human error…processes that rely solely on one staff member checking the actions of another or referring to written policies are not strong barriers.” It suggests that sufficient barriers are:
- Physical barriers
- Time and place barriers
- Systems of double or triple checking only where supported by visual or computerised warnings, standardised procedures, or memory/communication aids
However, the HSIB concluded that across the themes explored, the barriers in place were not sufficient to make an incident “wholly preventable”. They say that relying on administrative or behavioural barriers are not systemic barriers.
HSIB’s recommendations for never events
HSIB argue that putting the administrative or behavioural barriers in place is not sufficient enough to “wholly” prevent an incident happening. They also argue that the term “never” implies it should never happen. They say that this subsequently leads to healthcare professionals feeling guilty during an investigation. At Pryers we would agree that feelings of guilt and blame get in the way of a thorough investigation. People naturally become defensive if they think they are going to be blamed for something, so may be more secretive. This certainly doesn’t encourage learnings from mistakes to prevent them from happening again.
Systems Engineering Initiative for Patient Safety (SEIPS)
To combat this, they recommend a new investigation model called SEIPS. This model looks at all the factors relating to an incident rather than an individual action. This type of approach could help address the blame culture that appears to be embedded in the NHS. Which could hopefully improve communication between patients and healthcare trusts when mistakes happen.
Reclassification of never events
HSIB also recommends that NHS England reclassify seven of their never events to serious incidents, to remove the blame culture. NHS still investigate and report serious incidents, but with a slightly different focus than never events.
HSIB put a lot of focus on how the healthcare provider feels during an investigation and believe that this change in terminology will improve that position. However, is this really the answer? Will a simple change in classification remove those feelings of guilt? Let us not forget how serious some of these events can be. They include mistakes like operating on the wrong person or operating on the wrong body part; this could be operating on a healthy organ rather than the damaged one. There aren’t many healthcare providers who would not feel guilty if they realised that something they did led to that happening. Whether you call it a serious incident or a never event is irrelevant.
The HSIB are obviously concerned with the investigations within the NHS, but their considerations for the patient appeared minimal. Is it not fair to expect that your surgeon would ‘never’ operate on the wrong body part? What message would reclassifying these events do to patient confidence?
This HSIB report is purely a recommendation for NHS England. An NHS England spokesperson told The Guardian: “These incidents are extremely rare and our own review of never events, which is already underway, will consider HSIB’s findings as we continue to prioritise patient safety above all else and try to prevent this type of incident.”
Have you suffered from a never event?
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