Never events - a misnomer

never events

Medicine can never be a zero harm profession. Errors can and do happen, however careful the clinical and nursing staff. That is why the term 'never events' is a misnomer. But it has become an unhelpful shorthand for serious, preventable patient safety incidents that is in danger of deflecting attention from the real goal, which is continuous reduction in all patient safety incidents.

Professor Don Berwick, in his positively-received report A promise to learn, a commitment to act (August 2013), says: "While 'zero harm' is a bold and worthy aspiration, the scientifically correct goal is continual reduction. [...] the battle for safety is never won; rather, it is always in progress." He goes on to say that patient needs must take priority over organisational targets and reducing costs. Otherwise, healthcare providers may 'hit the target, but miss the point'.

Twenty five errors are classed as 'never events'. They range from wrong site surgery to retained foreign objects. In May 2013, a BBC investigation identified 762 never events in four years, including 322 retained items, 214 incidents of wrong site surgery, 73 misplaced nasogastric feeding tubes and 58 wrong implants or prostheses.

Some incidents result in claims against the clinician responsible. In the last 10 years, the MDU has been notified of 308 claims relating to retained foreign objects alone.

While NHS trusts should investigate any incident, the penalties for an organisation when a 'never event' occurs can be punitive. They must report the incident following national procedures and a significant financial penalty may follow. Both the phrase, and the financial penalties, create a stigma for individuals and organisations which is not conducive to a culture that should promote reporting and learning from mistakes.

The stated intention of the never events list - to encourage greater organisational focus on specific serious safety issues - is important, but limits the scope of organisation-wide improvement in patient safety.

It is a question of focus. When all attention is on a limited number of preventable patient safety events, incidents that fall outside the categories may not receive the attention they warrant. One example is administering penicillin to a patient who is allergic to it. The consequences - anaphylactic shock and even death - of this entirely preventable error would indicate that it should be treated with the same seriousness as a never event. But it is not on the list and carries no sanctions, so may be eclipsed by those that are.

We do not dismiss the distress these errors cause to patients and their families, but the classification is meaningless to them. They do not go into hospital expecting that only a certain category of errors should never happen. They rightly anticipate that their entire experience will be safe and error-free.

When MDU members call us for advice if there has been a mistake in patient care, we advise them to ensure the patient receives a sincere apology, and an explanation of what went wrong and how it will be put right. This is every doctor's ethical duty, and now also a contractual obligation under the duty of candour (explained in more detail on page 16).

Preventable things can and do go wrong, sometimes with severe consequences for the patient, and to the distress of the healthcare professionals involved. Professor Berwick argues for a transparent culture in the NHS where mistakes are reported and learning is shared to improve patient safety. We believe this is a far better focus, and more productive to overall patient safety, than determining whether an incident fits a never event category.

Dr Christine Tomkins
Chief executive

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