Medical blunders can’t be ‘never events’ as they could still happen

Health watchdog advises NHS to revise list of errors to avoid reinforcing blame culture in medicine

‘Changing the definition of these events does not diminish their importance

– they still need to be learned from’

‘There is a discord between saying an event should never happen and not having curbs in place to stop it’

MEDICAL blunders such as leaving foreign bodies inside patients after surgery should no longer be considered “never events” because the NHS is unable to guarantee they will never occur, a safety watchdog has suggested.

Never events are serious patient safety incidents that are supposed to be “wholly preventable” if healthcare providers have followed national guidance or safety recommendations.

Hundreds of these incidents occur in the NHS in England each year – almost 500 took place in 2018-19.

But a report by the Healthcare Safety Investigation Branch (HSIB) has recommended that seven never events out of 15 on the list should be removed until there are better barriers in place to reduce the risk of harm to patients.

Changing the definition of the incidents “doesn’t diminish their importance”, it added, but there is a “discord” between “saying an event should ‘never’ happen and not having effective barriers in place to prevent it happening”.

Never events which happened in 2018-19 included the case of a nineyear-old who received a drug by injection instead of by mouth prior to a kidney biopsy, a 30-year-old woman who had a swab left inside her following the birth of her first child and a 62-year-old man who had the wrong hip prostheses implanted during joint replacement surgery.

HSIB said that the analysis of these incidents found that the supposed barriers to prevent these events were “neither strong nor systemic”.

It has recommended that the NHS should review and revise the list, and work to create “systemic barriers for specific incidents where barriers are felt to be possible but are not currently available”.

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 well-being of staff and reinforces the perception of a blame culture.”

An NHS England spokesman said that mistakes were “extremely rare”, but it is currently reviewing the list of never events and would consider the findings of the HSIB.