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Showing results for tags 'Never event'.
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News ArticleAt least seven so-called NHS “never events” should be reclassified because the health service has failed to put in place effective measures to stop them from repeatedly happening, safety experts have said. The independent Healthcare Safety Investigation Branch (HSIB) said NHS England should remove the never event incidents from the list of 15 it requires hospitals to report, because they are not “wholly preventable” and the NHS has not adequately recognised the systemic risks that mean they keep happening. The errors include examples such as a 62-year-old man having the wrong hip replaced during surgery and a nine-year-old girl who was given a drug by injection that should have been given by mouth. Other incidents included a woman who had a vaginal swab left inside her following the birth of her first child and a 26-year-old man who had a feeding tube accidentally inserted into his lung rather than his stomach. In a new report, investigators from HSIB carried out a detailed analysis of seven incidents it has investigated which account for the majority of never events recorded by NHS hospitals in 2018-19. NHS England claims there are steps hospitals can take that mean the errors should never happen but HSIB says many of the steps are administrative, such as a checklist, and do not fully take into account the environment staff work in, the nature of the errors or how they happen. Read full story Source: The Independent, 21 January 2021
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News Article
Alert over hospital air devices after 120 ‘never events’
Patient Safety Learning posted a news article in News
NHS trusts are to be told to remove devices linked to more than 120 never events caused by ‘unconscious errors’. A national patient safety alert from NHS England which urges trusts to remove all air flowmeters from wall medical gas outlets. It is likely to be published next month. The alert comes after 121 never events in the last three years involved staff members accidentally connecting patients to air instead of oxygen. This number is close to 10% of all never events recorded during that period. These types of never events have been recorded by 57 NHS organisations during 2018-19, 2019-20 and 2020-21. The incidents took place mostly on medical wards and in emergency departments. They occurred despite NHSE issuing a patient safety alert in 2016, which recommended removing the flowmeters from wall outlets when not in active use. According to NHSE documents - seen by HSJ - the never events often went undetected “for some time”, even when other staff responded to deteriorating patients or took over their care. The regulator concluded this makes it more likely that there have been other unreported incidents. Read full story (paywalled) Source: HSJ, 17 May 2021 -
EventNever Events and serious Incidents are a cause for concern and anxiety when reported in an organisation. They require investigation and official reporting to the Care Quality Commision (CQC). The end result should be a process of open multidisciplinary analysis and discussion led by the Clinical Governance team that results in learning for the organisation. This process can be difficult and sensitive when harm is identified and errors attributed to processes and individual staff. In this webinar, we welcome representatives from the CQC and the National Orthopaedic Alliance (NOA) to discuss learning from never events and serious incidents. Register
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Zero harm and never events
Sam posted an event in Community Calendar
untilThis Q Community session: Introduces the concepts and origins of ‘never events’ and ‘zero harm’ as safety interventions. Explores and debates the usefulness of ‘never event’ and ‘zero harm’ initiatives as effective safety management strategies in healthcare. Reflects on and considers alternative approaches to managing risks of serious harm to as low as reasonably practicable. Further information Register -
Content ArticleNever Events are serious, largely preventable patient safety incidents that should not occur if healthcare providers are following national guidance and safety recommendations. In this blog John Tingle, a lecturer at Birmingham Law School, raises concerns about the number of Never Events that continue to take place within health services, the lack of public awareness about Never Events and the need to develop a safety culture that allows learning from Never Events to actually take place.
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Content ArticleAccording to new data released by the NHS, a total of 379 medical malpractices called ‘Never Events’ were recorded between 1 April 2021 and 28 February 2022. The term is defined by the service as “serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations.” See below Statista's chart representing the data.
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Content ArticleNever Events are serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations. This document details Never Events that were reported by NHS trusts in England between 1 April 2021 and 31 March 2022. Never Events are categorised by type of incident and by trust.
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Content Article
In this blog, Nigel Roberts, who is a registered Allied Health Professional theatre lead at the University Hospitals of Derby and Burton (which has in excess of 50 operating theatres and performs over 50,000 procedures annually), considers the current challenges facing all operating theatre staff post pandemic. Nigel looks at how human factors may influence the delivery of the surgical safety checklist, and discusses whether Local Safety Standards for Invasive Procedures (LocSSIPs) are making a difference in terms of the number of intra-operative Never Events being reported.- Posted
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Content ArticleThis literature review in The Operating Theatre Journal examines why the decision was made not to class surgical fires as a 'Never Event', even though research has identified them as a preventable hazard. The author also examines steps that could be taken to further reduce the risk of surgical fires in the NHS and other health systems. You will need to create a free online account to view this article.
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Content Article
Research shows that poor handover in hospitals puts patients at risk of severe harm
Anonymous posted an article in Handover
Research undertaken by digital health platform, CAREFUL shows that handover in hospitals is the cause of frequent and severe harm to patients. -
Content ArticleThis paper addresses information raised as part of a Delphi study of NHS hospital operating theatres in England. The aim of the first Delphi study round was to establish how the World Health Organisation’s Surgical Safety Checklist (SSC) is currently being used in the peri-operative setting as part of a strategy to reduce surgical ‘never events’. It used a combination of closed and open-ended questions that solicited specific information about current practice and research literature, that generated ideas and allowed participants freedom in their responses. The study asked theatre managers, matrons and clinical educators that work in operating theatres and deliver the surgical safety checklist daily, and who are therefore considered to be theatre safety experts. Participants were from the seven regions identified by NHS England. The study revealed that the majority of trusts don’t receive formal training on how to deliver the SSC, checklist champions are not always identified, feedback following a ‘never event’ is not usually given and that the debrief is the most common step missed. While the intention of the study was not to establish whether the lack of training, cyclical learning and missing steps has led to the increased presence of never events, it has facilitated a broader engagement in the literature, as well highlighting some possible reasons why compliance has not yet been universally achieved. Furthermore, the Delphi study is intended to be an exploratory approach that will inform a more in-depth doctoral research study aimed at improving patient safety in the operating theatre and informing policy making and quality improvement.
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Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Kathy tells us about the importance of breaking down barriers to share patient safety tools, and talks about changes she has implemented to make surgery safer. -
Content ArticleThis report represents the collective work of the National Patient Safety Consortium to identify, for the first time, a list of 15 never events for hospital care in Canada. Never events are patient safety incidents that result in serious patient harm or death and that are preventable using organisational checks and balances. Never events are not intended to reflect judgment, blame or provide a guarantee; rather, they represent a call-to-action to prevent their occurrence. But a list of never events won’t solve anything on its own. For it to have meaning, we need to take deliberate steps to identify when they occur, and harness the knowledge in hospitals across the country to prevent never events from happening. The Canadian Patient Safety Institute (CPSI) encourages a culture of continuous quality improvement — where mistakes are openly reported, disclosure occurs routinely and open discussion and problem solving are encouraged — with patients and families as full and active participants.
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Content ArticleThe Association for Perioperative Practice (AfPP) is calling for action to be taken after a recent never events report suggests little progress has been made to prevent errors within the perioperative environment.
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Content ArticleAHRQ PSNet is looking for interesting, provocative cases that illustrate key issues in patient safety such as medication errors, diagnostic errors, and adverse events that either had the potential for or resulted in patient harm. Cases from outpatient, ambulatory surgery, home health, long-term care, and rehabilitation settings are of particular interest. When a case is selected, the editorial team invites an expert author to write a commentary based on the case. Please note that case submitters do not receive any “authorship” because case submissions are anonymous. However, submitters of selected cases will receive a $300 honorarium. The AHRQ Patient Safety Network (PSNet) is a national web-based resource featuring the latest news and essential resources on patient safety.
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Content ArticleA 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.
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Content ArticleThis document defines the investigation framework in the event of a patient safety Serous Incident (SI) related to NHS Wales Informatics Service (NWIS) delivered or supported services, which affects one or more health body in Wales.
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Content Article‘Never events’ are patient safety incidents that are defined as being wholly preventable. They are considered wholly preventable because guidance or safety recommendations are in place at a national level and should have been implemented by all providers in the healthcare system. This should act as a strong systemic barrier to prevent the serious incident from happening. The latest national report from the Healthcare Safety Investigation Branch (HSIB) says that 'Never Events' should not be defined as such if they don’t have strong enough barriers in place to stop them happening.It recommends that seven Never Events on a list of 15 should be removed until better barriers are in place. They are using the Safety Engineering Initiative for Patient Safety (SEIPS) model to carry out the analysis. SEIPS provides a framework for understanding structures, processes and outcomes in healthcare, and their relationships.
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Content Article
Patient Safety Authority: Wrong-site surgery
Patient Safety Learning posted an article in Surgery
Analysis of wrong-site surgery events in Pennsylvania suggests opportunities for prevention. Many steps of preparing the patient for an operation and performing an operation can lead down the path of wrong-site surgery. Preventing wrong-site surgery may require attention at every step of the process. The Patient Safety Authority has provided resources, guidelines and education tools. -
Content Article
NHS England: Never Events data
Patient Safety Learning posted an article in Data and insight
NHS England publishes provisional Never Events data every month as an update of the cumulative total for the current financial year. The data is published in the following formats: the overall provisional number of Never Events reported in the current financial year to date – these are displayed by month. the provisional number of each type of Never Event reported, with a more detailed breakdown of sub categories of Never Event. the provisional number of each type of Never Event reported by an organisation. -
Content Article
Medical error prevention (5 May 2020)
Sam posted an article in Good practice
Medical errors are a serious public health problem and a leading cause of death in the United States. It is a difficult problem as it is challenging to uncover a consistent cause of errors and, even if found, to provide a consistent viable solution that minimises the chances of a recurrent event. By recognising untoward events occur, learning from them, and working toward preventing them, patient safety can be improved. Part of the solution is to maintain a culture that works toward recognising safety challenges and implementing viable solutions rather than harboring a culture of blame, shame, and punishment. Healthcare organisations need to establish a culture of safety that focuses on system improvement by viewing medical errors as challenges that must be overcome. All individuals on the healthcare team must play a role in making the provision of healthcare safer for patients and healthcare workers. -
Content ArticleWhen you are receiving treatment, it is important to feel that you are in safe hands. The Private Healthcare Information Network (PHIN) website publishes information on a range of patient safety measures, including about serious safety incidents. One category of these are known as Never Events. Here we explain what Never Events are, why they are measured, and how you can use them when considering which hospital is right for you.explain what Never Events are, why they are measured, and how you can use them when considering which hospital is right for you.
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Content ArticleThe Private Healthcare Information Network (PHIN) has published new information about serious patient safety incidents for private acute care. The data, covering the period 1 January 2019 to the 31 December 2019, show that 21 Never Events involving non-NHS (insured or self-pay) patients were reported.
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Content ArticleNever 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.
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Content ArticleThe aim of this study, published by the British Dentistry Journal, was to identify and develop a candidate 'never event' list for primary care dentistry.
