February 9, 2017

Never Events – the picture so far…

A 'Never Event' is a term used by the NHS to describe serious patient safety incidents which are largely or wholly preventable.  An incident is still classified as a 'Never Event' regardless of whether harm occurred. 

In March 2015, the way in which Never Events were defined and reported changed with a view to encouraging better reporting of incidents and improved learning.  The NHS prides itself on being one of the only healthcare systems in the world to be so "open and transparent about patient safety incident reporting". 

The total number of Never Events is published on-line on a monthly and annual basis.  In addition, the published data breaks the incidents down into Never Event categories and also lists the number of incidents by NHS Trust.  The aim of such openness is to achieve a reduction in the number of incidents as a result of shared and improved learning.  We have examined the data available to date to ask whether the openness is paying off or whether the number of incidents is increasing. 

As the way in which data was captured changed in March 2015, we have compared data covering the period from 1 April 2015 to 31 March 2016 with the data currently available from 1 April 2016 onwards.

The data for 2015-16 states that 442 Never Events took place over the course of the year with peak months being October and March.  Of these recorded incidents, the majority related to wrong site surgery (179), foreign objects being retained post procedure (107) or wrong implant / prosthesis (59).

The data for 2016-17 is not yet complete as there are still 3 more months of the year to go and the data will then need to be finalised once local investigations are completed.  However, 314 incidents have already been reported and these appear to be more evenly spread across the year.  So far, the majority of these incidents again relate to wrong site surgery (133), foreign objects being retained post procedure (75) or wrong implant / prosthesis (38). 

It remains to be seen how the rest of 2016-17 pans out for Never Events. However, if the first 9 months of the year are indicative, there may well be an overall reduction in the number of Never Events for 2016-17 in total and across the main categories, when compared to 2015-16.  This would suggest that the policy of openness and improved learning could be working. 

Any reduction in Never Events is to be applauded, but of course any Never Event is an incident too many and the human impact of these incidents should not be forgotten or trivialised.  It is still too early to say whether the openness of the NHS's Never Events policy is paying off with a reduction in the overall number of incidents. However, 9 months in, the picture is cautiously positive.