By John Tingle
“Never Events” — medical errors that should never occur — are a major and recurring problem in health care in England.
When they do occur, they sap confidence and trust in the health care system, and can result in significant injury or death to the patient. They can result in expensive litigation. There is also a significant financial cost to the NHS, which is always short of financial resources. The patient, their relatives, and all those involved in the incident bear emotional costs, too.
In the National Health Service (NHS), Never Events are defined and listed. The list includes such incidents as a foreign body being left in a patient, wrong implant/prosthesis, and wrong site surgery, among others. Sadly, the incidence of Never Events in the NHS is still too high.
Never Events are also a major patient safety metric that helps regulators such as the Care Quality Commission (CQC) and the public judge the safety of a hospital or other health care facility.
Recent publications highlight that Never Events remain a critical and a stubbornly persistent problem for the NHS to address.
Healthcare Safety Investigation Branch (HSIB)
The HSIB conduct independent investigations of patient safety concerns in NHS-funded care across England. They have done some major work on Never Events and most recently have produced a report on the mis-delivery of invasive procedures in outpatient settings.
This report is based on a situation where a 39-year-old woman who attended a gynecological clinic for a fertility treatment instead received a colposcopy intended for another patient. This reference event triggered HSIB to embark on a national investigation into the factors that may thwart the correct identification of patients in outpatient settings.
The report states that a better system of safety measures is needed to make sure patients are not mixed up and given the wrong invasive procedure during outpatient appointments. The report focused on looking at how effective existing risk controls were, and then looked at the risk factors for error.
Several risk factors for patients misidentification were listed in the report:
-Reliance on verbal communication
-The physical environment
-Clinical workload
-Design of the tools used to assist with patient identification
-Lack of integration of technology in outpatient departments
-Impact of patients moving around the department.
One safety recommendation — that outpatient settings review these risks relating to patient identification — was made.
CQC Investigation report
The Care Quality Commission (CQC) is the independent regulator of health and social care in England, and they publish reports of their investigations, which can include the occurrence of Never Events.
A recent investigation report focused on Never Events in University Hospitals Dorset NHS Foundation Trust. CQC found 13 Never Events reported by the Trust between March 2020 and January 2021. This number presents cause for concern.
NHS Resolution: Litigation and Never Events
NHS Resolution is an arm’s length body of the Department of Health and Social Care. They provide several functions, which include managing litigation claims made against members of their claims indemnity schemes, which include NHS hospitals and other health bodies. They maintain an important patient safety function and produce several publications. They recently published an insight publication on Never Events in the NHS on retained foreign objects post-procedure.
The report gives the costs of claims for incidents and the clinical specialty where the Never Event occurred. There is also advice about what health care providers can do about the Never Events problem:
“From 1st April 2015 to 31st March 2020, NHS Resolution received 800 claims for incidents of retained foreign object post procedure. Out of these 800 claims, 454 were settled with damages paid, 193 without merit and 153 remain open. This has cost the NHS £14,546,778.”
This includes payments for claimant legal costs, NHS legal costs and damages.
In terms of clinical specialty where these 800 never events occurred, they most commonly were attributed to general surgery (22%), with obstetrics following (13%), and then orthopedic surgery and gynecology (10% each).
Conclusion
There is no shortage of good advice from several NHS sources on how to prevent Never Events from happening, but they stubbornly persist. Unfortunately, the age-old problem of the NHS’s failure to learn lessons from past adverse health care events also applies to the occurrence of Never Events.
