By John Tingle
The Healthcare Safety Inspection Branch (HSIB) in England, which conducts independent investigations of patient safety concerns relating to the country’s National Health Service (NHS), has just published a learning report that examines the findings of investigations they have carried out on incidents classified as “Never Events.”
England’s NHS defines Never Events as “patient safety incidents that are wholly preventable,” in accordance with the implementation of “guidance or safety recommendations that provide strong systemic protective barriers.”
In the National Health Service’s policy and framework, Never Events are listed under the following headings: surgical, medication, mental health, and general. These headings include incidents such as overdose of certain medications, failure to remove a foreign object used during a procedure, and transfusion of incompatible blood.
The investigations for the HSIB report cover seven of the 15 types of Never Events listed in the National Health Service (NHS) Never Events policy and framework published in 2018. These seven categories account for over 96% of the total Never Events recorded in 2018 – 2019.
Controversially, the HSIB report recommends that NHS England and NHS Improvement revise the Never Events list to remove several which don’t have “strong and systemic safety barriers.” “These events,” the report states, “are therefore not wholly preventable and do not fit the current definition of Never Events.”
This suggestion is, arguably, not in the spirit of advancing the patient safety agenda in the NHS in England.
I have often thought, when reading statutes and thinking about statutory interpretation in my teaching, that language and words are an inefficient means of communication. That we can often convey more through facial expressions or gestures than words. It is useful reflecting on the point that in defining any term, legal or otherwise, that the label itself, the word, is arguably of secondary importance. It is the idea behind it that matters. When we analyze and collect the ideas behind the term, then we can begin to see the common accepted definition. This applies to patient safety and our understandings of “Never Events.”
The HSIB report identified 17 work system themes that contributed to the occurrence of the Never Events. These include: decision making, staff knowledge, team composition and roles, and interruptions. The report suggests that for many Never Events, including all those investigated in it, there are no strong and systemic barriers to stop them from happening. The Never Events therefore do not qualify, under the criteria set out under the NHS Never Events policy and framework, to be categorized as a Never Event. Thus, the report argues, they should be removed from the list.
I would argue against the HSIB recommendation that the removal of a significant number of Never Events from the official list is warranted on the basis that strong and systemic protective barriers don’t exist. These barriers do exist in some places, and the fact remains that these types of terrible adverse incidents are termed Never Events for a very good reason. So termed, they can act as a valuable deterrent to poor practices, and function as a valuable patient safety education medium.
We must look beyond the words, “Never Events,” beyond that label, to ascertain the true meaning of the term. We need to look at the context of patient safety in England. There have been many patient safety crises in the NHS over the years, and these problems continue to occur on an all-too-frequent basis. The official NHS Never Events list, as it currently stands, has an important value in developing a safer NHS. The concept of Never Events is also a useful patient safety accountability mechanism. We are better off having the full list than not, and it accords with general public and national patient safety policy sentiments.
It is important to recognize that concepts, terms, and words will maintain inherent ambiguities because of the limitations of language and the various meaning of words. Conceptual ambiguity is a natural feature of human discourse. We should not therefore reclassify a large section of our Never Events official list because of apparent definitional problems. There will always be conceptual ambiguity in complex terminology.