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The quest for the holy grail of patient safety is to find a solution to the stubborn reoccurrence of incidents that everyone accepts should never happen.
At a rate of more than one a day, patients in the NHS suffer “never events” such as wrong site surgery or equipment being left inside them.
Despite efforts to improve safety, the number of never events reported by NHS trusts has remained far too high. There were 469 such incidents reported between April 2017 and March 2018.
Former health and social care secretary Jeremy Hunt asked the Care Quality Commission to review why this was the case and how these incidents could be eradicated.
The World Health Organisation has backed the use of SOPs but critics have warned that the creation of yet another national process or protocol will not in itself prevent errors.
The NHS is awash with policies, guidance and protocols that staff working on the frontline in high pressure, safety critical roles rarely have time to stop, read and consider when delivering care.
A report and final recommendations are not expected until October.
It is early days in the investigation into the scope of the problem and there remains no direct evidence that patients have been harmed.
However, in a worst case scenario, it would mean thousands of people, including children, were not invited to cancer screenings, immunisation appointments, or a range of other routine tests.
The error relates to the recording of about 55,000 NHS patients on one national IT system but not another.
More will be revealed in the coming weeks, but already the problem shares many of the same characteristics of the breast screening scandal earlier this year.
An inquiry into women not invited to routine screenings because of an IT mistake (also relating to national systems, by some accounts), ultimately found that 75 woman’s lives were shortened as a result.
In both cases, the error occurred in a fragmented landscape of unwieldy IT systems and probably persisted for years before being escalated.