Being overly concerned with “never events” risks us missing wider, more important patient safety lessons, says Michael Devlin
The NHS is reviewing how it deals with “never events”. These are defined by NHS England as serious incidents that are “wholly preventable” because of systems in place at a national level. Examples include wrong site surgery, retained foreign objects after surgery and misplaced naso-gastric tubes.
While it’s right that the NHS strives to minimise medical errors, a fundamental question has yet to be addressed – is there a need for a never events policy at all? Some in the know have questioned the focus on never events with Professor Danny Keenan, Care Quality Commission national professional adviser, commenting:
“It remains to be seen if [the expanded never events] list contributes importantly to safety. From CQC’s point of view, never events are the tip of the iceberg. The iceberg is a trust’s overall approach to safety.”
The iceberg analogy is apt. If we concentrate on what is readily visible, at the tip, we risk not paying enough attention to the dangers that lurk below the surface. So it’s time to take stock and challenge the orthodoxy that promotes never event frameworks as an effective solution to the constant effort to make patients’ care as safe as possible.
It might seem audacious, or counter-intuitive, to argue against the logic of eliminating never events in the NHS. No doctor or healthcare professional wants harm to come to a patient. But we must be realistic and realise that safety incidents do occur. The MDU believes that the focus on these specific patient safety incidents distracts from a cohesive approach to analysing and understanding why things go wrong and hinders public perceptions about the standards of care.
Never events are about stopping one particular behaviour. The MDU’s view is that patient safety initiatives should have a much wider focus
Never events, almost by definition, are set up to fail. The presumption is that they should never occur, so when they do (as the evidence shows) the credibility of those striving to improve patient safety is dealt a massive blow. The public perception, articulated in criticism from the Patients Association, is that standards of care must be falling if the same errors occur time and again.
The truth is that when patient safety incidents occur, there are usually several factors at play. Never events are about stopping one particular behaviour, or introducing a new, safer way of doing something but only in specific cases. The MDU’s view is that patient safety initiatives should have a much wider focus.
When things go wrong what is important is that lessons are learnt to prevent future recurrence. Individuals must still be accountable for their actions, but the primary focus should be on organisational and systemic factors, which are where the root causes of safety incidents usually lie.
This will help NHS organisations move “from a blame culture to a learning culture” that Jeremy Hunt desires. Money trusts currently pay out in financial penalties when never events occur would be better reinvested in trying to improve patient safety across the board.
The Healthcare Safety Investigation Branch was recently established and in time its learning should complement the expertise that already exists in NHS Improvement. The two bodies are well placed to evaluate patient safety incidents; the former to carry out independent investigations and the latter to analyse the data it receives from NHS organisations.
Rather than focus on an arbitrary list of never events, which serve no one and distort public perceptions, the NHS would be better to focus on implementing initiatives that are proven to work to help improve patient safety. Doing so will be entirely consistent with the “culture firmly rooted continual improvement” advocated by Professor Don Berwick (see page 6).
Dr Michael Devlin, MDU head of professional standards and liaison