Michelmores Update: 'Never' Events on the Rise
'Never events' are the health industry term to describe medical mistakes so serious, and so preventable, that they should never happen. After a Freedom of Information request from the Health Service Journal revealed that 299 such events took place last year, double the number in the previous assessment, the NHS will now publish quarterly reports listing their occurrence.
There are 25 never events listed by the NHS; below is a selection.
retained foreign object post-operation
- misidentification of patients
- entrapment in bedrails
- wrong route administration of oral/enteral treatment
- wrong gas administered
- maladministration of Insulin
The last point, regarding Insulin, may prove significant in the upcoming prosecution of Mid Staffs hospital. 66 year old Gillian Astbury slipped in to a diabetic coma and died after nurses failed to realise she needed the drug.
The definition of a never event, according to the NHS guidance, is that it is 'preventable if the national guidance and/or national safety recommendations are implemented'. Opposition MPs have seized upon the recent statistics as evidence of the effects of spending cuts on the health service, citing the rapid decline in the past year.
However, Don Berwick, in his review of patient safety in the NHS, takes a more conciliatory view. Among his recommendations is the following, much-quoted passage:
While 'Zero Harm' is a bold and worthy aspiration, 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.
Somewhere between the hopeful idealism of Berwick and the Westminster knife-fight lies the core issue of patient safety, and what needs to be done to safeguard it.
Michelmores Clinical Negligence team provide a link to the Daily Mail article on never events; please click here to view .
If you would like to discuss an issue arising from treatment at an NHS hospital or clinic, you can contact our specialist solicitors for discreet, impartial advice.