Thursday, 18 February 2016

Never Events

The Patients Association has described as a disgrace the 1200 "never events" reported to have occurred in the NHS in the last 4 years.

The BBC stated that a Press Association investigation had revealed 1190 such events in the NHS from April 2012 to December 2015:

"The so-called never events included the case of a man who had a whole testicle removed rather than just a cyst.
In another, a woman's fallopian tubes were taken out instead of her appendix.
NHS England insisted such events were rare, but the Patients Association said they were a "disgrace".
Other "never events" included the wrong legs, eyes or knees being operated on and hundreds of cases of foreign objects such as scalpels being left inside bodies after operations."

Paradoxically it might be more reassuring if there had been more "never events". This NHS England list of "never events" shows that the categorisation of an error as a "never event" is tightly circumscribed. A surgical intervention performed on the wrong patient or wrong site (for example wrong knee, wrong eye, wrong limb, wrong tooth or wrong organ) is a never event but such incidents are not "never events" if they are due to incorrect laboratory reports or incorrect referral letters. It doesn't matter much to the patient whether the patient operated on the wrong knee because of a mistake by the surgeon or a mistake by the doctor making the referral but the former is a "never event" whilst the latter is not.

NHS England defines "never events" as "serious incidents that are wholly preventable as guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers."

Of course never events should never happen, but it is surely of some concern that so few errors are regarded as being wholly preventable. The NHS treats a million patients every 36 hours. The fact that only 300 or so errors a year are classified as wholly preventable seems to me to be rather worrying. We should be concerned that there are so few "never events"!

If systemic barriers were more effective then there would be more errors classified as never events. There would be more mistakes regarded as inexcusable. Human error can never be eliminated, but if systems are improved then the number of errors can be reduced and fewer patients will suffer avoidable harm. The total number of harmful errors might well decrease but the number regarded as inexcusable might well increase.

The number of never events is not a good measure of the the quality of care and patient safety within the NHS. If the NHS classifies only 300 errors a year as "never events" then it suggests that it has a very narrow view of which errors should never occur.

As a clinical negligence lawyer I am hardly ever involved in "never event" cases, but rather with medical errors that are regarded as excusable. Perhaps if systems improved and fewer of those were tolerated, then there would be a reduction both in the number of clinical negligence claims, and the number that were defended.


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