The gap was illustrated through an investigation that focused on a case of wrong tooth extraction. Wrong tooth extraction was categorised as a Never Event* and therefore HSIB sought to understand the ‘barriers’ that exist in the pathway of care for wrong tooth extraction.
The report identifies that while there are controls in place to prevent wrong tooth extraction, they invariably rely on staff to be effective and should not be regarded as ‘strong systemic protective’ barriers. The investigation went further to examine the differences in how the NHS defines and assures barriers in comparison to other safety-critical industries such as oil, gas, nuclear and aviation. The report sets out that in healthcare, the term ‘barriers’ is used generically to refer to measures put in place to prevent the occurrence of patient safety incidents. In other industries, the term is well-defined and has a specific meaning.
Section Four of the report focused on Barrier Management – the process of ensuring that safety controls are robust enough to protect against serious adverse events and their consequences. One of the investigation’s key findings is that whilst most safety critical industries have invested heavily in systems, often mandated by regulatory bodies, for identifying, analysing and assuring barriers, the NHS has not.
Dr Stephen Drage, Director of Investigations says: “ As with many of our other reports focused on Never Events, this report emphasised what we continually see across the NHS; there are not clearly defined, well managed and strong systemic barriers in place to reduce safety risks.
“What this report specifically highlights is the success other safety critical industries have had. The learning from this report for all across the NHS is that it’s not only crucial to identify controls intended to prevent harm but to consistently review and ensure that they are still effective and promoting safety in ever-changing environments.”
Another key finding in the report is that the description of what constitutes ‘barriers’ is not clearly defined in the NHS Never Events policy and framework and is inconsistent with other literature. As a result, one recommendation has been made to NHS England and NHS Improvement to review and ‘explicitly define’ what can be considered a ‘strong systemic protective’ barrier. This recommendation aligns with the findings and recommendations of the Never Events National Learning Report published in January 2021.
*Following discussions in November 2020 between the HSIB, NHS England and NHS Improvement safety team, and key stakeholders representing dental professionals, it was agreed that wrong tooth extraction did not meet the criteria for a wrong site surgery Never Event. It was removed from the Never Events list, effective as of 1 April 2021