Should we continue to have Never Events in healthcare?

An operating theatre, close up on surgical equipment

This month the Healthcare Safety Investigation Branch (HSIB) published its report analysing their investigations of Never Events, the National Learning Report – Never Events: analysis of HSIB’s national investigations.

What is a Never Event?

 As described by HSIB:

‘Never events’ are patient safety incidents that are defined as being wholly preventable. They are considered wholly preventable because guidance or safety recommendations are in place at a national level and should have been implemented by all providers in the healthcare system. This should act as a strong systemic barrier to prevent the serious incident from happening.

Events on the Never Event list include things such as:

  • Wrong site surgery
  • Retained foreign object post procedure
  • Administration of medication by wrong route
  • Mis-selection of high strength midazolam during conscious sedation

These are all things which are entirely preventable if safety recommendations are followed.  However they continue to happen because procedures are not followed.

Why do Never Events keep happening?

The HSIB National Learning Report identifies several common themes.  Some common themes are listed below.#:

  • Decision making
  • Staff Knowledge or lack of training
  • Interruptions
  • Variability of tasks
  • Design of Tools or work area
  • Co-ordination and variability of organisational guidance and alerts

Examining a few of these:

Decision making – the investigation found that complexity and time pressure in our healthcare system results in clinicians making unconscious mental short cuts during decision making.  Eg selection of a prosthetic from the packaging size and material without seeing or processing other relevant information.

Interruptions were found to be a common cause of error leading to unintentional or missed actions during a task.

Design of technology made errors more likely such as air and oxygen flowmeters connect to tubing using the same connector design or prostheses packaging not being clearly labelled.

Conclusions from the HSIB investigation

 There are numerous work systems with contribute to the occurrence of Never Events.  Whilst some Never Events can be minimised by a process which can be managed such as limiting the opening of windows to prevent falls, some Never Events involve complex processes and where the safety mechanism involves a checklist or similar which relies upon human interaction and behaviour.  Where the barrier involves behavioural elements the human factor weakens the process and increases risk.

HSIB therefore raise concern about the use of the word ‘never’ and the fact that effective barriers are not available.  This leads to culpability, guilt and the implication of blame and liability.

Interviewed by the Independent newspaper, Dr Sean Weaver, deputy medical director at HSIB said:

“Our findings challenge the definition of these incidents as never events. This doesn’t diminish their importance; they still need to be recorded and learnt from but we recognised that there is a discord between saying an event should ‘never’ happen and not having effective barriers in place to prevent it happening.
“This continues to have an impact on the safe care of patients, affects the wellbeing of staff and reinforces the perception of a blame culture.”

HSIB recommends that the Never Events list is revised to remove events where strong systemic safety barriers are not available but maintains the need for these events to be investigated to improve patient safety outcomes where possible.   This will continue to improve patient safety whilst hopefully removing blame from the equation when things go wrong.  Only when a culture is blame free can there be an open dialogue and learning to prevent events happening in the future.

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