George Gallagher discusses why Never Events keep happening, why they matter and what we can all do about them to improve outcomes
Never Events are defined as ‘Serious Incidents that are wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers’.1 Despite their name, Never Events do happen and are surprisingly common. There were 314 serious incidents that met the definition of a Never Event between 1 April 2021 and 31 December 20212– that is more than one ‘entirely preventable’ event a day
Most obviously, they present a significant risk to patient safety and can lead to harm and even death, but there are a whole host of other consequences that impact patients and providers indirectly – including clinical negligence claims, delays in subsequent treatments, increased costs, and the effect on staff morale.
Furthermore, the Never Events policy and framework – revised in January 2018, suggests Never Events may highlight potential weaknesses in how an organisation manages fundamental safety processes3 – in other words, they are often a symptom of a much larger issue.
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