Monday, 29 July 2013

Events that should Never Occur

Patient safety and healthcare quality initiatives started in earnest in the USA in the late 1990s/early 2 noughties. Similar initiatives introduced in the NHS over the past 10 years have migrated from across the pond. One such initiative is the compulsory reporting of what is termed a 'never event'.

The peculiarly termed never event is exactly that - something that, in the eyes of someone somewhere should never ever happen. As with many healthcare safety initiatives, the concept of a never event has been borrowed from the aviation industry. Good examples of never events include a surgeon operating on a wrong limb and accidental retention of a gauze swab inside a body cavity after surgery.

Comparing the English list to the American list makes very interesting reading -The most obvious difference is that the American list is much longer and that many items on one list do not exist on the other. The other big difference is the consequence of a never event happening. In the US where there is a predominantly private competitive healthcare system, publication of a list of never events by a hospital will very likely lead to less business and therefore less income. In the UK, a carrot and stick approach is used to manage the occurrence of never events in hospitals. The response is designed to ensure that processes are put into place to ensure those never events do not occur again.

The number of possible events that should never happen in hospital are innumerable. Different wards and specialities will have their own particular never events. It is impossible that every event in every corner of the hospital could be included in an infinitely long list of never events. There is however, merit in the publication of a hospital's performance as regards the occurrence of generic never events. The number of never events occurring in a hospital reflects its general approach to patient safety. They have featured in the recent Keogh report on underperforming hopsitals. Publication of these lists is in my opinion a positive and important development. I just hope that access to the performance of all hospitals in England hospital will be easy and straightforward for patients and that eventually occurrence of never events will become vanishingly rare.