NHS England has published the most comprehensive data, so far, on 'never events', which include incidents such as wrong-site surgery, swabs and other medical equipment being left inside patients, and drugs being administered incorrectly.
For the first time, provisional quarterly data on the number of never events happening at each hospital Trust in England has been published on line, for both the general public and healthcare professionals to view. Until now, data has been published only annually, and only at national, aggregated level. The data is now available on the NHS England website, and will be updated in three months’ time. From April 2014, the data will be updated every month.
The provisional data shows:
- 102 NHS Trusts had at least one never event between April and September this year.
- 8 independent hospitals had at least one never event between April and September this year.
- There were 37 instances of wrong-site surgery in the six months from April to September, and 70 incidents of foreign objects being mistakenly left inside patients.
NHS England points out that there are 4.6 million hospital admissions that lead to surgical care every year in England, and 500,000 non-Caesarian births. There are also tens of thousands of other interventional procedures like internal radiology and cardiology catheter procedures that are also classified as 'surgical' in terms of never events. So the incidence rate is less than 0.005% or 1 never event in every 20,000 procedures.
The data shows that the number of never events recorded is broadly similar to last year. NHS England expects that reporting of these incidents will continue to increase as the NHS becomes a more transparent and learning system, and as the types of incidents that are classed as 'never events' continue to increase in line with developments in patient safety practices.
Dr Mike Durkin, National Director of Patient Safety at NHS England, said: “Awareness in the NHS of these issues has never been greater and the quality of our surgical procedures has never been better. It follows that the risk of these things happening has never been smaller.
“Every single never event puts patients at risk of harm which is avoidable. People who suffer severe harm because of mistakes can suffer serious physical and psychological effects for the rest of their lives, and that should never happen to anyone who seeks treatment from the NHS.
“But is time for some real openness and honesty. There are risks involved with all types of healthcare. And one of those risks – with the best will in the world and the best doctors, nurses and other healthcare professionals in the world – is that things can go wrong and mistakes can be made. This has always been the case, and it is true everywhere in the world.
“This publication is not about ‘naming and shaming’ – it is about telling the public about mistakes, and further ensuring that we talk about and learn from them. That is the way to minimise errors and take every step we can to drive avoidable harm out of the NHS.
“By making this detailed data fully open to public scrutiny, we are fulfilling a key recommendation of the Francis Review, but more importantly we are making a big step towards further reducing these events. As Professor Don Berwick made clear in his report on patient safety earlier this year, these incidents can only be truly minimised if we talk about them in an open and honest way, and all work together to make sure every effort is being made to stop whatever went wrong from happening again.”
Professor Don Berwick said: “No one who works in any hospital wants to see patients come to any harm at all. When serious errors occur, it is a tragedy for both patients and staff, so the courage and commitment shown by the NHS in publishing this data are admirable.
“One way to help improve safety is by openly and honestly recognizing, discussing, and examining mistakes in care. That helps us create continually better systems and procedures.
“Blame and punishment have no productive role in the scientifically proper pursuit of safety. But openness and transparency do. They are the front door to learning and improvement. I applaud NHS England for this important step toward better knowledge and better support to both staff and patients.”
