Recommendations Aim To Eradicate Never Events

255 Surgical "Never Events" Were Reported In The UK In 2012-13

03.03.2014

A specialist group has set out a series of recommendations to help healthcare providers cut down on the number of "never events" being reported.

The Surgical Never Events Taskforce has offered advice to NHS England, which is keen to find new ways to improve the safety of surgical procedures.

Never events is the term used for mistakes that should not happen due to the amount of clear guidance that is available.

There were 255 of these cases reported in the UK in 2012-13, ranging from surgeons who performed an operation on an incorrect part of the body to objects mistakenly being left inside a patient's body.

In its report, the taskforce highlighted three key areas in which hospitals can improve.

Firstly, the group stated that a set of high-level standards need to be applied across the country and that an Independent Surgical Investigation Panel is established.

It also noted that better education is required, with all operating theatre staff being given rigorous training.

Lastly, the taskforce called for greater harmonisation and consistency in the reporting of never events, as this would enable surgeons to learn from mistakes made by others.

Given the fact 4.6 million hospital patients require surgical care in the UK every year, the number of never events being recorded is relatively low, but NHS England is eager to find out why some incidents are slipping through the net.

Dr Mike Durkin, director of patient safety at NHS England, remarked: "Patient safety has come a very long way in the past few years, and there has been a real revolution in how we monitor, manage and learn from incidents and build systems to minimise the risks of surgery. But every single never event is one too many."

Meanwhile, Clare Marx, council member and patient safety lead at the Royal College of Surgeons, welcomed the recommendations, suggesting that educating entire surgical teams is "fundamental" and all staff must be able to learn from past errors.

Expert Opinion
Never events should be just that – events that simply do not happen and it is imperative that Trusts across the entire country invest in training to ensure every step is taken to protect patients and prevent injury where at all possible.

“Following the occurrence of a never event, each Trust should undertake a root cause analysis report to get to the bottom of exactly how and why something could go so seriously wrong and it is encouraging that these guidelines are being put into place.

“Many of our clients contact us as they are frustrated at the lack of information that they have been given about why there were errors in their care. Each Trust must provide clear, transparent information to patients who have fallen victim to a never event to help them come to terms with their ordeal and provide reassurance that steps have been taken to improve patient safety in future.”
Lisa Jordan, Partner