I was giving a presentation at a patient safety event recently on Never Events and somebody mentioned to me how Never Events could now be referred to as ‘Always Events’. I have heard the term ‘Common Never Events' and have used that term myself in previous columns, but the concept of Always Events was new to me and shocking. This raises the issue that Never Events have possibly now become so commonplace in the NHS that they are part of everyday practice and do not hold the significance they once had. Are Never Events morphing from ‘Common’ to ‘Always’ Never Events?
The meaning of Never Events
In its seminal report, Opening the Door to Change, the Care Quality Commission (CQC) (2018) stated:
‘What sets Never Events apart is that they are believed to be wholly preventable by the implementation of the appropriate safety protocols. Despite this preventability, the number of Never Events has not fallen. About 500 times each year we are not preventing the preventable.’
Never Events feature in CQC inspection reports and get picked up in the national media. In 2020, ITN News reported:
‘The Royal Cornwall Hospital Trust has admitted several serious errors in patient care in the past six months since April 2020. The hospital's chief executive has confirmed there have been eight of the so-called ‘Never Events’. In one, a heart patient was left with a piece of wire inside them. The hospital trust has apologised.’
In the mind of the public and of lawyers the term Never Event is given a common, literal meaning as something that should never happen, a quite exceptional and critical adverse healthcare event. But, if we see them regularly occurring, I suspect nurses and doctors could begin to become desensitised to the term. These events might begin to lose their exceptional status.
Reclassification
The Healthcare Safety Investigation Branch (HSIB) (2021) has developed an interesting and, arguably, worrying view of Never Events. It discusses reclassifying some of these events owing to the failure of barriers to prevent them. The report states:
‘The analysis of the 10 Never Events included in this report found barriers that were neither strong nor systemic. These events are therefore not wholly preventable and do not fit the current definition of Never Events.’
Recommendations have been given to NHS England/NHS Improvement to revise the NHS Never Events list and to start a programme of work to address the issues HSIB highlighted.
Don't dilute the term Never Events
When analysing terms such as ‘Never Events’, it is important to also look at the ideas behind the label. Labels themselves can change over time, it is what they are describing or relating to that is key. The words Never Events seem to perfectly describe the event of operating on the wrong patient, leaving a foreign body in them, or operating on the wrong limb or part of the body. If these events were not called Never Events, how else would we ascribe their importance as a critical error?
By any calculation or meaning, these are terrible, unforgivable events that should never happen in a modern-day NHS. It is possible to overthink or over engineer concepts and debate about terminology. Debate and discussion are essential to keep concepts alive and relevant. However, in doing this, we must be careful not to throw the baby out of with bath water as far as Never Events are concerned.
The latest Never Events data
Reading the most recent Never Events report published by NHS England/NHS Improvement (2022) has given me a deep sense of concern, along with a marked loss of confidence in how the NHS is handling patient safety. The lessons of past Never Events occurrences seem to go unlearnt in parts of the NHS. The same errors can be seen to be repeated time after time.
This also raises the question of what steps nurses and doctors can take so that these events are reduced in number and hopefully do not happen. HSIB (2021) and CQC (2018) provide a thorough discussion of the problems and opportunities to deal with these issues but that is not stopping these types of events from happening. We could be making a steady drift from Never Events towards Common Never Events and possibly Always Never Events, which is most concerning. The NHS England/NHS Improvement report (2022) states that:
‘407 Serious Incidents appeared to meet the definition of a Never Event in the Never Events list 2018 (published 28 February 2018) and had an incident date between 1 April 2021 and 31 March 2022.’
NHS England/NHS Improvement, 2022: 6
The report advises that this number is subject to change as local investigations are completed. This compares with the previous report (NHS England/NHS Improvement, 2021) where 364 Serious Incidents appeared to meet the definition of a Never Event and had an incident date between 1 April 2020 and 31 March 2021.
This increase in Never Events further compounds the seriousness of the issues. All nurses, and doctors involved with patient safety policymaking, training and education should read these Never Events reports (NHS England/NHS Improvement, 2021; 2022). They provide essential patient safety materials for study sessions and discussion. The reports should also filter through into Never Event training sessions in the relevant specialties discussed in the reports. The latest report provides details on the types of Never Event and numbers, including:
- Wrong site surgery: 171
- Retained foreign object post-procedure: 98
- Wrong implant/prosthesis: 47
- Misplaced nasogastric or orogastric tubes and feed administered: 31.
Wrong site surgery
Wrong site surgery Never Events included:
- Angiogram intended for another patient: 1
- Biopsy from wrong breast: 1
- Colposcopy intended for another patient: 1
- Embolisation to the wrong area of the kidney: 1
- Removal of ovaries when surgical plan was to conserve them: 1
- Resection of wrong eye muscle during squint surgery: 1
- Toe procedure intended for another patient: 1
- Wrong side pacemaker placement: 1.
The removal of ovaries when the surgical plan was to conserve them would be absolutely devastating for the patient, as are all the other events listed.
Retained foreign objects post-procedure included:
- Part of a pair of wire cutters: 1
- Laparoscopic specimen bag: 2
- Scalpel blade: 1
- Vaginal swab: 32
- Surgical swab: 21.
The report (NHS England/NHS Improvement, 2022) also provides details of the trusts where the Never Events have taken place. Some trusts record as many as 9 or 10 Never Events, with one recording 11.
The way forward
In my long experience of commentating on patient safety and legal matters, the issue that I predominantly see is the fact that patients are being avoidably, and I will also use the legal term negligently, harmed through lack of care. They are being harmed by those who are meant to care for them. The harm is not deliberate, but it is still harm to vulnerable patients who have trusted healthcare staff to look after them.
Healthcare staff have legal and professional duties to act professionally, to keep up to date and to provide good care. Yes, there may be systemic issues at play, which HSIB (2021) alludes to, and weak barriers, but that should not result, for example, in the removal of ovaries when the surgical plan was to conserve them, as discussed above. Something is very wrong with our care system when this sort of things happens, and it is a Never Event by any use of the terminology and cannot be excused.
Professional responsibilities
Reflection on what it means to be a professional is one way forward in tackling Never Events. The lessons of previous cases of Never Events should be discussed and learnt through study days or training sessions. Using podcasts, or whatever is the latest way of passing information and training through to staff, should be adopted.
Patient safety huddles
There is a direct correlation between health care litigation and complaints. This is well known within the legal community that handles cases and many NHS staff who deal with these issues will agree with this statement. If we improve our channels of communication between each other and our patients, then fewer Never Events and other types of patient harm will occur. I want to share a useful way of communicating that I have seen used effectively in the retail sector, ‘the team huddle’.
In a team huddle, staff get together for a brief time before or at the end of a shift to discuss and reflect on what has occurred. I know this might be difficult for staff in a busy resource-constrained environment such as the NHS, but it is worth considering. These huddles are already carried out in parts of the NHS, but I think they need a higher profile. Chauhan (2022) described the process of pre-shift team huddles:
‘Team huddles are more than just a staff meeting. They're a place for consistent, regular discussion in which employees at all levels communicate, share, and address key performance indicators and areas of improvement. The purpose is to provide an open channel where your team members can safely share any questions or concerns they may have.’
The Leading Change, Adding Value Team (2019) give an NHS context to huddles:
‘100% of respondents found the huddle to be useful as it identified and allocated roles and created familiarity between team members.’
Leading Change, Adding Value Team, 2019
Conclusion
The NHS is always short of money and I suspect it always will be, that is our model of health care. It faces daily an almost tsunami-level demand for limited healthcare resources. At the same time, the Never Events that are being recorded are unforgivable lapses of care and should not be happening with the frequency that they are. There are weak barriers in place to stop Never Events occurring in some parts of the NHS but that does not excuse them or warrant calling for a rename of these types of events. These are unforgivable lapses of care by any measure of the word. NHS England/NHS Improvement (2022) provide a useful national picture of healthcare providers' Never Events occurrences and the healthcare providers mentioned in the report should all work tirelessly to prevent their occurrence.