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HSIB recommends overhaul to NHS list to ensure ‘Never Events’ are truly never events

by Communications team

Our latest national report states that Never Events should not be defined as such if they don’t have strong enough barriers in place to stop them happening.

It goes on to recommend that seven Never Events on a list of 15 should be removed from the list until there are better barriers in place to reduce the risk of harm to patients.

We reached these conclusions following a detailed analysis of 10 of our investigations. The patient safety incidents in the investigations cover the seven areas which account for 96% of the total Never Events recorded in 2018/19.

These include the case of a 62-year-old man who had the wrong hip replacement put in during surgery and that of a 9-year-old child who was given a drug by injection that should have been given by mouth.

Challenging the definition of ‘Never Events’

Our report identifies that the current barriers for these events do not make the events ‘wholly preventable.’ They are therefore not Never Events according to their definition.

As a result, we have made two recommendations to NHS England and NHS Improvement:

  • Revise the Never Events list to remove events, such as those presented in this national learning report, that do not have strong and systemic safety barriers.
  • Develop and commission programmes of work to find strong and systemic barriers for specific incidents where barriers are felt to be possible but are not currently available.

Dr Sean Weaver, Deputy Medical Director at HSIB says: Our findings challenge the definition of these incidents as Never Events.

“This doesn’t diminish their importance; they still need to be recorded and learnt from but we recognised that there is a discord between saying an event should ‘never’ happen and not having effective barriers in place to prevent it happening.

“This continues to have an impact on the safe care of patients, affects the wellbeing of staff and reinforces the perception of a blame culture.”

Themes from across the work system

The report sets out 17 themes from across the ‘work system’ that contribute to the occurrence of Never Events.

The most common themes identified across all investigations included variability in task performance, design of technology, design of workplaces, coordination, and variability in organisational responses. We emphasise that a key theme is the ineffective barriers to Never Events.

The report presents evidence that barriers for the investigated events are either limited or do not exist. They emphasise that many are administrative in nature, for example use of checklists or second-checking of a task.

Dr Weaver continues: “The number of themes we identified demonstrates the challenge for the NHS, not only in trying to ensure that Never Events don’t happen, but also in identifying suitable barriers.

“However, in the report we have also emphasised what this may look like. The other eight Never Events on the list of 15 happen much less often and this therefore implies stronger barriers, for example restrictions to prevent falls from hospital windows and limiting access to high-strength medicines.

“Although the myriad of work system factors showcases complexity, identifying them pinpoints where patients, staff and trusts are most at risk of Never Events happening. The safety recommendations we developed are aimed at changing the approach.

“Taking these Never Events out of the current list can still allow the search for more effective barriers where these are possible and in turn improving patient care and making it safer. This is especially important as the knock on effect of Covid-19 on existing patient safety risks can’t be underestimated.”

Examples of incidents from HSIB reports

Some of the Never Event reference cases that underpinned HSIB’s published investigations include:

  • a 9-year-old child who was wrongly given an oral drug intravenously before a kidney biopsy
  • a 30-year-old woman who had a vaginal swab left inside her following the birth of her first child
  • a 62-year-old man who had the wrong hip prostheses implanted during joint replacement surgery
  • a 26-year-old man who had a nasogastric (NG) tube accidentally inserted into his lung following treatment after a bike accident.
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