Rush to reduce elective backlog increasing ‘never events’, report finds

Moving less complex procedures out of operating theatres and into other care settings to free up capacity to support elective recovery has ‘inadvertently’ increased the risk of ‘never events’ at an acute trust, a report has warned. 

The warning was made in a report into four never events at North Bristol Trust’s Southmead Hospital between November 2022 and January 2023 – two of which involved the same patient. 

The review was commissioned by Bristol, North Somerset and South Gloucestershire integrated care board to examine common issues in never events involving invasive procedures. It found an increase in never events when procedures were moved away from operating theatres to other care settings. 

The review found moving procedures from theatres to outpatient or day case facilities to “support the reduction in the [elective] backlog and improve the waiting times for patients… may also inadvertently increase the risk of never events”. 

It added: “It is likely that a theatre environment has more established and embedded safety control mechanisms. Governance processes in moving such procedures should consider the impact on quality, for example, the gaps between safety processes and consideration of the minimum requirements for the new procedure location.”

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Source: HSJ, 29 November 2023