Never events in UK general practice. A survey of the views of general practitioners on their frequency and acceptability as a safety improvement approach

Summary

Never events (NEs) are serious preventable patient safety incidents and are a component of formal quality and safety improvement (Q&SI) policies in the UK and elsewhere. A preliminary list of NEs for UK general practice has been developed, but the frequency of these events, or their acceptability to GPs as a Q&SI approach, is currently unknown.

This study from Stocks et al., published in the Journal of Patient Safety, aimed to estimate the frequency of 10 NEs occurring within GPs' own practices and the extent to which the NE approach is perceived as acceptable for use.

Content

Key findings

• The study findings suggest that the designation of a NE as a NE is dependent on the individual/type of NE and that NEs were reportedly rare.
• Although GPs were more likely to disagree with the NE label for the more frequently occurring NEs, this was not in proportion to their increased frequency of occurrence. 
• Most GPs remained unconvinced that the risk can be eliminated for any of the NEs.
• GPs do, however, seem to take the actual and potential occurrence of such events seriously given that 99% stated an intention to undertake a significant event analysis after a NE.
• Opinions varied widely with some GPs commenting that the risk of serious harm was extremely low, whereas other GPs suggested that the NE should be more stringent.
• Some GPs felt that the NE description was placing a burden of responsibility on them that was not intended by the description of the NE; for example, that they should be responsible for the actions of a laboratory or the ambulance service.
• There were differences in opinion about the level of responsibility a GP should take for the actions of non-medical staff.