Never Events: The Big Debate

Summary

On Wednesday 1 May 2024, the National NatSSIPs Network hosted a webinar to discuss the NHS England consultation on the Never Events framework. The consultation is concerned with whether the existing framework is an effective mechanism to drive patient safety improvement. This blog gives an overview of the discussion at this webinar, which had over 200 participants.

Content

The NHS England Never Events policy and framework defines Never Events as:

“Serious Incidents that are wholly preventable because 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. Strong systemic protective barriers are defined as barriers that must be successful, reliable and comprehensive safeguards or remedies—for example, a uniquely designed connector that stops a medicine being given by the wrong route.”

In February 2024 a consultation was opened seeking views on whether the existing Never Events Framework remains an effective mechanism to drive patient safety improvement. This follows the findings of reports such as the Care Quality Commission’s Opening the door to change and the former Healthcare Safety Investigations Branch’s analysis of Never Events, which highlighted that for several types and sub-types of Never Events, the existing barriers were not strong enough to make an incident wholly preventable.

Considering its effectiveness, the consultation asks respondents which of the following options they would prefer for the future of the Never Events framework:

• Option 1: No change; continue with the current framework.
• Option 2: Abolish the Never Events framework and list.
• Option 3: Revise the list of Never Events to only include those with current barriers that are ‘strong, systemic, protective’.
• Option 4: Revise the definition of and process for Never Events to create a new system that does not require all relevant incidents to be ‘wholly preventable’.

Webinar panel

This webinar, held to discuss these proposals, was chaired by Dr Annie Hunningher, Consultant in Anaesthesia and Group Safety Lead at Barts Health NHS Trust. She was joined by the following panel:

• Claire Cox, Patient Safety Lead at King's College Hospital NHS Foundation Trust and Founder of the Patient Safety Management Network.
• Dr Claire Morgan, Consultant in Restorative Dentistry, Patient Safety Specialist at Royal London Hospital, Barts Health NHS Trust and Deputy Chair for the Patient Safety Group for the Royal College of Surgeons of Edinburgh.
• Helen Hughes, Chief Executive of Patient Safety Learning.
• Professor Iain Moppett, Professor of Anaesthesia and Perioperative Medicine and Honorary Consultant Anaesthetist at the University of Nottingham and Nottingham University Hospitals NHS Trust.
• Kellie Bryan, Head of Patient Safety Investigations and Patient Safety Specialist at University Hospitals Sussex NHS Foundation Trust.
• Dr Samantha Machen, Associate Director of Patient Safety and Head of Patient Safety Incident Response at University Hospitals Sussex NHS Foundation Trust.

Initial opinions

At the beginning of the webinar, a poll was conducted to ascertain initial views on which of the four options in the consultation attendees favoured. The results, pictured below, showed that the fourth option had the greatest support among those in attendance.

Attendees were also asked to state the first word that came to mind when asked the question ‘Is the Never Events Framework an effective mechanism to drive patient safety improvement?’ Their responses resulted in the word cloud pictured below.

Key themes and issues

Subsequently, each of the panellists was asked to set out their views on the Never Events framework and consultation proposals. This was interspersed with and followed by comments and questions from attendees of the webinar and conversations between the panel. 

There was a consensus that protecting patients from avoidable harm is the number one priority, but the question was how to do this within the current healthcare system and environment. Below are some of the themes and issues that emerged from this lively and engaging debate.

‘Wholly preventable’ incidents

Reflecting on a key issue raised by option 4 in the consultation, whether Never Events need to be revised so that they are not required to be ‘wholly preventable’, there were a number of comments by panel members and attendees. There was a suggestion that making this change would not be a significant departure from the status quo, but simply a recognition of the practical reality that many of these events are not ‘wholly preventable’.

The difference between ‘work as imagined’ and ‘work as done’ in relation one specific type of Never Event, the scalding of patients, was also discussed. It was noted that while in principle hospitals should be able to put in place a series of mitigations to reduce the risk of this, what is done in practice can be significantly limited in ageing hospital estates with outdated infrastructure. These challenges are not recognised by the existing framework when considering this type of incident as ‘wholly preventable’.

Another example given by one of the presenters considered a case study of wrong intraocular lenses, a type of wrong implant/prothesis Never Event. Although initially this may appear ‘wholly preventable’, an investigative approach revealed a significant degree of complexity that is not adequately addressed or mitigated by existing checking procedures. 

Indicators of patient safety

There was considerable discussion around how the reporting of Never Events is currently used and whether this is a useful means of measuring overall patient safety in an organisation.

It was noted that Never Events data only represents a small part of all the healthcare and patient safety activity in an organisation. Furthermore, it is focused on specific areas of care, with three surgical Never Events broadly accounting for around 80% of all Never Events in total. It was suggested that this narrow scope means that organisations’ performance in relation to Never Events, good or bad, is not necessarily a reliable indicator of the approach to safety across an organisation.

The issue was also raised that the current incidents listed as Never Events apply to procedures that are much more frequent in Acute Trusts. So, while you would be likely to have significantly fewer Never Events at a Mental Health or Community Trust, this isn’t an indicator of higher levels of safety at those organisations, just of a measure being set by NHS England.

Public visibility and transparency

Panellists and attendees discussed the level of public attention and focus that Never Events received compared to other patient safety incidents, highlighting the following points:

• The purpose and benefit of publishing the names of organisations and their numbers of Never Events in the public domain is unclear. There is no context or nuance to help the public understand or find balance (such as numbers of surgeries performed or the size and complexities of the Trust, for example, teaching hospitals).
• Public awareness of Never Events appears to be low. One attendee noted that people do not tend to look at this data until they are impacted by it, at which point it is too late. The patients and families that do look at Never Events do so because they have suffered from one of these incidents.
• Simply publishing the number of incidents alone is not a good measure of safety. The data as currently published does not consider responses to these incidents or accompanying plans for improvement.

The term ‘Never Event’

A prominent issue of discussion was the appropriateness of the description ‘Never Event’ itself. Some in attendance suggested it felt disingenuous to patients, staff and public given the consistent number of these incidents that continue to occur, implying that this can be reduced to zero. Alternative names were posited, such as ‘Priority Safety Events’. It was noted that ‘never’ is not often used in other safety critical industries, and hazard management phrases including 'as low as reasonably practical' should be considered.

The point was also raised by several participants that the term itself could be seen as punitive, contributing to a blame culture. In a counterpoint, it was suggested that this stemmed from wider issues of a lack of safety culture in parts of the NHS. In this context, changing the name of Never Events will not address the problem.

Level of attention and focus on Never Events

Another significant area of discussion in the webinar concerned whether too much emphasis is placed on Never Events, distracting from other areas of patient safety focus.

It was noted that although a significant amount of time and resources is invested into investigating Never Events, there is little evidence to suggest this is translating into wider system level improvement. In the context of this, it was suggested by some participants that the current approach to Never Events could be seen as disproportionate. It was suggested that this may be particularly the case under the new Patient Safety Incident Response Framework (PSIRF) where all Never Events, regardless of the level of harm, will require a full Patient Safety Incident Investigation (PSII).

An example was given that if a patient had an incorrect mole removed, this would be classed as a Never Event (a form of wrong site surgery) requiring a full PSII, despite being a low harm event. Under PSIRF, this may be prioritised for investigation at the exclusion of a full investigation of missed diagnosis of a serious condition, despite the latter potentially resulting in a much more significant level of patient harm.

There were also points raised about the opportunity cost of focusing significant resources on Never Events. Examples of this include:

• Not looking more closely at the majority of cases when Never Events do not happen, learning from when things go right and the activities and behaviours that lead to this.
• Whether a focus on Never Events lets system leaders ‘off the hook’ for significant safety issues elsewhere by defining events in such a narrow way.
• Not considering near misses more closely. A participant suggested that reporting of these can low because of the lack of capacity to report these and insufficient capacity in patient safety teams.

Consequences of abolishing Never Events

Reflecting on a key issue raised by one of the four options in the consultation, whether Never Events should be abolished, there were a number of comments by panel members and attendees.

There were concerns about the negative perception this may create, including:

• Even if there is a strong rationale for removing this term, it could be seen as a reduction in transparency around the occurrence and frequency of these incidents. 
• It could be interpreted as a signal that we are giving up the ambition of that these types of incidents should never occur.
• For a patient or family member involved in a Never Event with serious life altering consequences, it was noted it would be difficult to see how such a change could be viewed positively and not undermine their trust in the healthcare system.

A concern was also raised that with some of these incidents being so rare, abolition of the Never Events framework may result in a loss of visibility for serious patient safety incidents. It was suggested this may reduce leadership focus on issues such as wrong site surgery and retained foreign objects. This could potentially reduce opportunities for investigation and improvement.

Redefining Never Events

At the beginning of the webinar, the proposed consultation option to revise the definition of Never Events was most favoured among attendees. Considering what this might look like, the following points were made:

• There should be a focus and priority given to the level of harm, rather than simply the type of incident. Events with catastrophic implications for patients should be prioritised.
• Focus should not be simply on reporting the number of events, but how they are responded to. What corresponding investment and training is put in place to address problems that have been identified?
• The events included in the definition should be expanded. Suggestions of this included types of incorrect medicine administration and surgical fires.

Concluding views

During the webinar, a poll asked whether participants had ever been involved in a Never Event, which produced the results pictured below.

To close the webinar, another quick poll was conducted to ascertain whether participants’ views on the four options in the consultation had changed. The results, pictured below, showed a significant growth in support for the second option, ‘Abolish the Never Events framework and list’, at the end of the debate. However, significant support remained for the fourth option to ‘Revise the definition of and process for Never Events to create a new system that does not require all relevant incidents to be ‘wholly preventable’.

There is still time to share your views with NHS England on whether the existing Never Events Framework remains an effective mechanism to drive patient safety improvement.

The consultation is open to responses until Sunday 5 May 2024—respond and share your views.

Networks on the hub

This webinar was hosted by the National NatSSIPs Network, a voluntary group of healthcare professionals aiming to reduce the number of patient safety incidents related to invasive procedures. 

the hub hosts and supports a growing number of informal peer support networks for people involved in patient safety, providing a forum for meeting up, discussing and sharing ideas and initiatives, and learning from others. We also host the Patient Safety Management Network, an innovative network for patient safety managers and everyone working in patient safety.

You can join by signing up to the hub today. When putting in your details, please tick the relevant Network in the ‘Join a private group’ section. If you are already a member of the hub, please email support@PSLhub.org. 

Related reading

• National learning report: Never Events analysis of HSIB's national investigations report (21 January 2021)
• How can Never Event data be used to reflect or improve hospital safety performance? (1 May 2021)
• The National Safety Standards for Invasive Procedures (NatSSIPs) (January 2023)
• Why are surgical never events still occurring: A Delphi study research sample across NHS England operating theatres (17 June 2023)

You can also find a number of existing resources, tools and stories relating to Never Events on the hub.