Is the ‘never event’ concept a useful safety management strategy in complex primary healthcare systems? (January 2021)

Summary

A sub-group of rare but serious patient safety incidents, known as ‘never events,’ is judged to be ‘avoidable.’ There is growing interest in this concept in international care settings, including UK primary care. However, issues have been raised regarding the well-intentioned coupling of ‘preventable harm’ with zero tolerance ‘never events,’ especially around the lack of evidence for such harm ever being totally preventable.

Bowie et al. consider whether the ideal of reducing preventable harm to ‘never’ is better for patient safety than, for example, the goal of managing risk materialising into harm to ‘as low as reasonably practicable,’ which is well-established in other complex socio-technical systems and is demonstrably achievable.

They reflect on the ‘never event’ concept in the primary care context specifically, although the issues and the polarised opinion highlighted are widely applicable. Recent developments to validate primary care ‘never event’ lists are summarised and alternative safety management strategies considered, e.g. Safety-I and Safety-II.