Number of reported “never events” is “disturbingly high”

The number of ‘never events’ being reported by the NHS is increasing. Patients falling out of windows and equipment being left inside wounds after surgery were some of a near record number of ‘never events’ recorded last year.

Life-threatening medical mistakes are ‘disturbingly high’ – with official data revealing that wrong site surgery took place 178 times in the 12 months before April 2017. Surgical swabs were mislaid inside patients after operations on 22 occasions, and in two cases broken-off drill bits were mislaid.

These were among a litany of 424 never events recorded in 2016-17, which included 18 operations on the wrong knee and some cases where oral medicine was administered intravenously. Misplaced vaginal swabs were a common problem across the English health service, with 31 cases recorded, while 42 procedures on the wrong tooth took place. On four occasions, doctors operated on the wrong patient. As well as medical mishaps, three patients fell from improperly restricted windows, and in three cases a patient’s neck or chest became trapped in their bed rails. Among the offenders in 2016-17 was St Bartholomew’s NHS Trust, responsible for 11 transgressions, whilst King’s College Hospital NHS Foundation Trust was responsible for seven. The latest figures show a steady increase in the number of wrong site surgeries, with 54 such incidents reported in 2012-13, rising to 135 in 2015-16.

NHS chiefs have suggested that the rising number is due, in part, to a greater awareness of never events amongst staff – which has resulted in increased reporting: ‘Organisations are expected to investigate and learn from mistakes, and the fact that more and more NHS staff take the time to report incidents is good evidence that this learning is happening locally.’

What can be done to reduce these medical errors that so often lead to litigation and expensive damages payments? Is their rising incidence really the result of ‘greater awareness’, as opposed to being a reflection of an NHS system under intense pressure? Do post your own thoughts and suggestions.

Comments (4) Add yours ↓
  1. Declan Cahill Consultant Urologist

    Thank you Roger.
    One mustn’t forget the adage that those that have no complications do no surgery.
    We are incredibly productive. That productivity comes with a degree of haste and there is an equation of balance.
    The never event concept means that mistakes are constantly learnt from. It’s harsh. We can’t ignore the event. Learning always happens.
    It’s a slightly odd group. Wrong site is clearly a disaster. The job has not been done. All the others are regrettable complications that we need to manage.
    Nothing ever goes under the carpet. It’s all about learning doing better and not doing it again.
    I’ve had a retained needle. Never event. Patient fine. No harm. Learning done. Less likely in the future.
    Continuous process improvement. It’s what we do. Frailty. Honesty. Getting better and more robust.

    August 29, 2017 Reply
  2. Christian Brown Consultant

    Around 5 years ago a patient that was under my care sustained a skin burn in theatre due to a faulty warmer excessively warming irrigation fluid. I will never forget it and I still see her for renal cancer follow up and I am reminded of the event every year. It led to a trust change in policy for the use of positioning aids and an over haul of servicing contracts for electronic appliances.

    Without transparency and a full investigation nothing would have changed with the potential for the event to occur again.

    My issue with the current checks is that many don’t see value in the WHO and go through the motions without really considering the questions and their implications. I’m sure never events such as wrong side or wrong patient surgery rarely occur in a ‘normal’ day but at times when everyone is under pressure with late starts, change of list order, being called to a meeting or another theatre and new staff being present which wont go away.

    I embrace the team brief, WHO checklist and being around in theatre for the duration of my list and basically being involved at every level. A certain level of legal paranoia is healthy just not too much……..

    August 30, 2017 Reply
  3. Justin Vale Deputy Medical Director for Safety & Effectiveness

    By definition, never events are errors which should never occur because there are systems and processes available which, if fully implemented, would prevent them.
    There are two broad patterns of never event in my experience: clusters and sporadic. When a cluster of similar never events occur within an organisation, it suggests a failure of effective implementation of a system or process. Within my own institution in 2014, we had 3 misplaced nasogastric tubes in relatively quick succession. In response we revised our NGT policy to include more rigorous methods for confirmation of position, extensively publicised the policy change, and introduced an e-learning package to better educate trainees in the correct interpretation of chest X-rays to confirm NGT position. We have had no further NGT incidents since.
    Sporadic never events are more worrying. Having investigated a number of these myself, the common theme is typically a failure to follow processes that have been implemented to protect patients – and ourselves. For example, and most relevantly, I have witnessed a failure of operating surgeons to show leadership and participate in basic safety checks. In three cases, the operating surgeon did not participate in the time-out: in one case the result was wrong side surgery and in the other two, the wrong implant was inserted. I have investigated serious incidents (not never events) relating to failure of the anaesthetic team to check the consent form before performing anaesthesia, and failure of the surgeon to engage in the sign-out leading to failure to manage the pathology specimen correctly.
    I think the level of never events should be a wake up call to all healthcare professionals to own and, where necessary lead, the basic safety processes that common sense would dictate should occur in all interventional procedures. Perhaps the most worrying thing about the cases I have investigated is that in nearly all cases every box on the WHO checklist had been ticked, yet on investigation it was clear that it was seen as box-ticking rather than the important patient safety tool that it is. I think some healthcare professionals have forgotten what a privilege it is that patients place their total trust in us to look after them when they are at their most vulnerable; the least we can do is respect that trust by embracing simple tools which allow us to protect them from unnecessary risk.

    September 4, 2017 Reply
  4. Roger Kirby Professor of urology

    It also emerged yesterday that the NHS received a record number of written complaints last year – up 5 per cent compared to the previous 12 months, prompting criticism that the health services is struggling to cope. The data shows a 9.7 per cent rise in written complaints to GP and dental practices.

    “More and more people are not getting the standard of care they have a right to expect,” said Liberal Democrat health spokesman Norman Lamb. “Staff are battling to deliver the best care under difficult circumstances, but the pressures facing the NHS are simply not sustainable. It threatens to be a long winter ahead.”

    A Department of Health spokesperson said: “Hardworking NHS staff treated more than 1.7 million patients in A&E within four hours in August, more than 56,000 a day. The NHS has robust plans in place ahead of winter to ensure patients continue to receive safe and efficient care as demand increases, supported by £100m of additional funding.”

    September 15, 2017 Reply

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