Michael Devlin: No more “never events” 

The MDU’s Michael Devlin argues the never events policy has had a limited effect on patient safety and welcomes a reassessment by the Healthcare Safety Investigation Branch.

Patient safety is rightly a priority for everyone in healthcare but for too long, the focus has been on the reductive concept of “never events,” rather than giving every patient safety incident the same level of attention to see what lessons can be learned and shared.

Never events are defined as “serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations.” They are designed to act as a red flag for improvement by NHS organisations.

More than a decade has passed since the first list of eight never events was published in 2009 and in that time the number of events on the list has waxed and waned—at one point there were 25—but they continue to occur, despite our best efforts.

The most recent summary from NHS England shows 226 never events occurred between 1 April – 30 November 2020 including 87 categorised as wrong site surgery, 52 retained objects, and 18 misplaced naso- and oro-gastric tubes.  

The MDU has always regarded the term “never event” as a misnomer because we are no closer to eradicating these errors. More importantly, we believe the emphasis on a limited list of specified errors is unhelpful because it paradoxically deflects attention from the real goal of improving safety across the board. We are concerned that the policy creates stigma and blame which is not conducive to the open, learning culture to which we all aspire.

More than ten years on from that first list of never events, a reassessment is timely even in the midst of the current pandemic. Which is why the Healthcare Safety Investigation Branch (HSIB) national learning report into never events is important. 

Based on its own national investigations, such as wrong site surgery—wrong patient and the placement of nasogastric tubes HSIB concluded: “The analysis of the 10 Never Events included in this report found barriers that were neither strong nor systemic. These events are therefore not wholly preventable and do not fit the current definition of Never Events.” 

The report makes three significant recommendations: that NHS England and NHS Improvement revise the never events list to remove events that do not have strong and systemic safety barriers; that safety barriers to avoid incidents are developed where possible; and that the National Safety Standards for Invasive Procedures (NatSSIPs) policy is revised to standardise safety critical steps common across procedures.

At the MDU we often support members dealing with the emotional and medico-legal impact of an incident. We agree with this latest report that it is necessary to think about such incidents differently with more of a focus on reporting and learning from incidents. Sadly, it is not always possible to prevent patient safety incidents from happening, but preventative actions can and should be taken. 

The report also highlights the possible impact of the pandemic on patient safety, not least the consequence of factors such as increased fatigue, redeployment of staff and the difficulties of communicating while wearing PPE. 

The persistent use of the word “never” reinforces the unhelpful concepts of blame and liability and is a distraction from what really matters. Rather, we should focus on creating an open and learning culture that supports those involved (patients, families and staff) along with finding out what went wrong and learning lessons so that similar events can be prevented in future. 

Michael Devlin is Head of Professional Standards & Liaison at the MDU.

Competing interests: none declared.