Medical blunders should leave ‘never’ list, says watchdog
MEDICAL BLUNDERS such as a wrong hip replacement and a nine-year-old who received a drug by injection instead of by mouth should no longer be considered “never events”, a safety watchdog has said.
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. But now the Healthcare Safety Investigation Branch (HSIB) has recommended that a number of these incidents should be removed from the list.
It said 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.
HSIB said that changing the definition of the incidents “doesn’t diminish their importance” but said that there is a “discord” between “saying an event should ‘never’ happen and not having effective barriers in place to prevent it happening”.
The organisation examined a number of never events which occurred in the NHS in 2018/19.
These included:
■ A nine-year-old child who was wrongly given an oral drug intravenously prior to a kidney biopsy
■ A 30-year-old woman who had a vaginal swab left inside her following the birth of her first child
■ 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.”