Almost 150 “never events” recorded in six months

  • Date: 23 December 2013

FOREIGN objects left inside surgical patients and wrong-site surgery were the most common “never events” recorded by NHS trusts in England.

Provisional figures from NHS England show that between April and September 2013 there were 148 “never events”, a number of which caused death or serious harm to patients.

Never events are described as “serious, largely preventable patient safety incidents that should not occur if existing national guidance or safety recommendations had been implemented by healthcare providers”.

This is the first time such detailed data has been published, with a breakdown of the type of event that occurred and at which hospital trust in England. Figures have previously only been published annually at a national level. The information will be updated in three months’ time and then monthly from April 2014.

The figures show there were 102 NHS trusts and eight independent hospitals who reported at least one never event between April and September. With 4.6 million admissions leading to surgical care every year, the incidence rate is less than 0.005 per cent, or one never event in every 20,000 procedures.

There were 69 reported instances of a retained foreign object post-operation. There were also 37 reports of wrong site surgery, which included the excision of the wrong skin lesion, a procedure on the wrong finger, and the removal of a fallopian tube instead of the appendix.

The use of the wrong implant/prosthesis was the third most common never event with 21 reports, followed by seven reports of inappropriate administration of daily oral methotrexate.

In five instances, a misplaced nasogastric tube caused death or severe harm. There were two instances each of maladministration of potassium-containing solutions causing death or severe harm, and patients being transfused with the wrong blood type causing death or severe harm.

The number of never events recorded has been found to be broadly similar to last year, but NHS England expects that improved reporting will lead to a rise in such incidents.

Dr Mike Durkin, National Director of Patient Safety at NHS England, said the publication of this data fulfilled one of the key recommendations of the Francis report following patient deaths at Mid Staffs.

He said: “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.”

The report has been praised by US expert Professor Don Berwick who led a landmark review into patient safety in England earlier in 2013.

He said: “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 is admirable.

“One way to help improve safety is by openly and honestly recognising, discussing, and examining mistakes in care. That helps us create continually better systems and procedures.”

• Read the full report on the NHS England website

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