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Why are ‘never events’ still occurring?

Concerns have been raised about patient safety at Royal Cornwall Hospital this week after 11 serious incidents were reported in June, including a never event.

A never event is a serious, preventable incident which should not occur and can put patients at risk of harm.  In this incident a wrong implant was used in an endoscopy procedure.

However a recent NHS publication noted that a further 2 never events had been reported at Royal Cornwall Hospitals NHS Trust (RCHT) between April and June this year.

It is perhaps more worrying to note that the report revealed a total of 107 never events occurred across NHS hospitals in just the same period. A never event should simply not happen if procedures are followed and preventative measures are in place.

The most frequently occurring never event was wrong site surgery, including incidents of the wrong hip and wrong eye being operated on. The second most common incident reported was retained foreign objects following procedures. Surgical swabs, needles and part of a drill bit were all reported to have been left behind in patients after treatment. According to the same NHS report published last year, 7 patients underwent unnecessary procedures in 2015/2016 simply due to wrong patient identification.

A spokesperson for the RCHT was reported to state that the care and safety of patients is the Trust’s top priority and “the open reporting of incidents is an essential part of learning and reducing risk of their recurrence”.  

It is crucial that a never event is investigated in order to learn and take action on the underlying causes of any simple, avoidable mistakes. Simple medical errors occurring may be a warning that a hospital’s systems for implementing safety advice and alerts may need reviewing and improving.

RCHT commented further that "Any never event is subject to a rigorous investigation and the outcome shared with the patient or family concerned, as well as being reviewed and discussed by the clinical teams involved and, where appropriate, shared more widely throughout the NHS."

It is important that any outcomes are shared throughout the NHS as it appears that never events are happening all too often.

To discuss this or a related issue with myself or a member of the clinical negligence team at JMW please use the contact form or call us.  


 

 

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