Should we change our attitude towards 'never events'?

Twenty-five errors in the health service are considered so intolerable and inexcusable that they have been designated 'never events'. They include wrong-site surgery, retained foreign objects and administering chemotherapy by the wrong route.

When a never event occurs, the organisation concerned must follow national procedures for reporting and investigating what happened and may pay a significant financial penalty. The object of the policy introduced in 2009 is to encourage greater organisational focus on specific serious safety issues. The problem with categorising certain incidents as never events is that it may divert attention from the most important goal of improving patient safety across the board. The term is also misleading because these events do occur, usually because of a combination of chance and human error, factors that can never be totally eliminated. In his positively received report into NHS patient safety Professor Don Berwick states: "'Zero Harm' is a bold and worthy aspiration, [but] the scientifically correct goal is 'continual reduction'. All in the NHS should understand that safety is a continually emerging property, and that the battle for safety is never 'won'; rather, it is always in progress."

In May 2013 a BBC investigation identified 762 never events in four years, including 322 retained items and 73 misplaced nasogastric feeding tubes. I do not believe the categorisation never events is helpful. This is not to dismiss the distress these errors cause to patients and their families, but the term and the financial penalties create a stigma for individuals and organisations, which may not be conducive to a culture that should promote reporting and learning from mistakes. When our members, who are 50% of UK GPs and hospital doctors, approach us for advice about what to do if there has been a mistake in a patient's care or treatment, we advise them to ensure the patient receives a sincere apology, together with an explanation of what went wrong and how it will be put right. Irrespective of whether the incident was a never event, it is vital that there is a full investigation and that steps are taken to avoid the incident happening again.

For patients who are harmed, the last thing on their minds is probably whether it was a never event. There are incidents in which patients are harmed that fall outside the classification. One example is where patients have been given a drug, such as penicillin, to which they have a known allergy. The consequences of this could be anaphylactic shock and even death and in many cases the error could have been prevented by taking and recording of a medical history, checking records before administering medication and checking if the patient is wearing a red wristband. These preventable errors must be treated as seriously as a never event but there is a risk they may not get the same attention.

Medicine, even when properly and carefully practised, is not a zero-harm or a zero-risk profession.

Preventable things can and do go wrong, sometimes with severe consequences for patients and to the distress of the healthcare professionals involved.

Berwick argues there is a need for a transparent culture within the NHS where mistakes are reported and learning is shared to improve patient safety. Patients who have suffered harm because of any medical error should rightly expect that what happened to them has been the subject of a thorough investigation to determine what happened, why and what lessons have to be learned. Wouldn't it be better to concentrate on this than on determining whether an incident classifies as a never event?

This article is courtesy of theguardian.