Tackling transfusion ‘Never Events’

To quote former Chief Medical Officer, Professor Sir Liam Donaldson, “When you look back after someone has been killed in a patient safety incident, you can often see that all the ingredients were in place for a disaster to happen.” Despite this being well recognised, in recent years, adverse incidents involving morbidity and mortality to NHS patients, due to human error, are still at unacceptably high levels and continue to rise. The National Patient Safety Agency (NPSA) previously defined a patient safety incident as ‘any unintended or unexpected incident which could have or did lead to harm to patients receiving NHS care’. Organisation Patient Safety Incident data released in 2012 by the NHS Commissioning Board Authority revealed that the number of patient safety incidents in England occurring between 1 October 2011 and 31 March 2012 was 612,414 – representing an increase of 2.3% compared to the previous reporting period. Some 90% of NHS Trusts in England submitted incident reports to the National Reporting and Learning System (NRLS) for this set of data, which further revealed that 68% of patient safety incident reports resulted in no harm to the patient, 25% resulted in low harm, 6% resulted in moderate harm, while 1% resulted in death or severe harm. The most common types of incident reported were patient accidents, namely slips, trips and falls (26%), medication incidents (11%), and incidents relating to treatment and/or procedures (11%). Commenting on these figures, Mike Durkin, director of patient safety, NHS Commissioning Board Authority, said: “We are working to ensure the new system will drive improvements in patient safety. NHS organisations should use this data and review the tools, guidance and support available to them. This will ensure patient safety incidents continue to be reported and learned from, thereby strengthening the patient safety culture across all levels of the NHS.”

 Never Events

In an attempt to reduce the more commonly re-occurring and serious adverse patient safety incidents, in 2010 the Department of Health produced a draft list of eight types of incidents which it termed ‘Never Events’. These are defined as serious, largely preventable patient safety incidents that should not occur if the relevant preventative measures have been put in place. Because Never Events are devastating and deemed preventable, healthcare organisations are now under increasing pressure to eliminate them completely. As a result, the list has since been updated and currently consists of 25 Never Events on the expanded list. The list covers areas such as surgical, product or device incidents, as well as areas relating to patient protection or care management. Specific examples on the Never Event list are ‘wrong site surgery’, ‘incorrectly prepared high-risk injectable medications’, ‘retained foreign objects post-operation’, and ‘incorrect administration of medicines or treatments’ such as insulin, potassium containing solutions and chemotherapy. However, according to a recent BBC investigation, more than 750 NHS patients have suffered following preventable mistakes over the past four years, many of which were actually on the Never Event list, including operating on the wrong body part or leaving instruments inside patients. The figures, compiled through Freedom of Information requests to NHS Trusts, discovered that the majority of mistakes fell into four categories. There were 322 cases of foreign objects left inside patients during operations, 214 cases of surgery on the wrong body part, 73 cases of feeding tubes being inserted into patients’ lungs by mistake and 58 cases of wrong implants or prostheses being fitted. NHS England has since acknowledged that these figures are too high and said that it has introduced new measures to ensure patient safety, as well as starting to collate data to help educate staff on better practice. An NHS England spokesperson added: “We need to understand what it is in some hospitals that has not produced an effective outcome which has led to a Never Event.”