Strategies for reducing the risk of Never Events

Twenty years ago, a sentinel report To Err is Human started an awareness of the safety of patients during treatment. While it was a report published in the US, it started the development of a new science and many new activities in global healthcare and in the NHS. A great deal of progress has been made since that initial report, but there is always more to do. Healthcare is dynamic and there is a need to continuously evaluate in order to improve patient safety and services. NHS Improvement’s patient safety strategy¹ cites three distinct strategic aims which are:

There are many patient safety incidents reported by acute and primary care, by mental health facilities and also by ambulance Trusts. They are regularly recorded on the National Reporting and Learning System and can be accessed individually by staff members and patients to report incidents. The number of adverse incidents (reported in 2019) resulting in death was 4,600, with 4,356,277 patient safety incidents reported overall.² It was also noted more recently (2019-2020) that there were 435 Never Events in NHS care, and that this number remains stubbornly the same each year.³

The Care Quality Commission⁴ was asked to look at the patient safety culture in NHS and, in 2018, it reported on the different attitudes of healthcare and other high-risk industries. The other industries regard their work as high-risk and this informs everything they do. Safety alerts are implemented effectively and consistently; an understanding of team dynamics, situation awareness, and human factors are central to how they work. Safety protocols are followed without question. Staff are expected to raise matters of safety concern and do so as a matter of course. If safety is in any way compromised, then operational processes are stopped without hesitation. Safety training is never considered to be optional.