Patient safety – Never Events
We are all at risk of adverse events when we use healthcare service and we all stand to benefit from preventing them. ‘Never events’ are “serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented by healthcare providers”.1
Eight ‘never events’ were introduced to the NHS in April 2009. The government is proposing to expand this list to 25 events, listed in the appendix below.2
When a ‘never event’ occurs, the patient or the patient’s family are informed, the incident is reported, the root causes are investigated and any recommended changes are made.1 The healthcare provider is not paid for the episode in which the event occurred, nor any care required as a result.2
Evidence of the possible benefits
The policy has been shown to be feasible. It is used in the USA and Canada, where mandated reporting and investigation of a list of ‘never events’ covers a population of 82.9 million.3
Minnesota introduced a ‘never events’ policy in 2003, which was evaluated in 2008. The proportion of respondents who felt that patient safety was a very high priority increased from 33% in 2003 to 69% in 2008. Most respondents (72%) felt that healthcare was safer overall since 2003, although other initiatives may also have contributed to this. Good practice specifically prompted by the ‘never events’ policy included: sharing adverse event data, leadership walk-arounds, setting measurable patient safety goals and assessing patient safety culture. The increased number of ‘never events’ is thought to reflect improved reporting and wider definitions.4
Feedback from English healthcare providers suggests that the 2009 ‘never events’ policy has increased the focus on patient safety within institutions, and has prompted local implementation of patient safety initiatives.1
Clear evidence that a ‘never events’ policy improves health will require good quality intervention studies, which have not been conducted so far.
Evidence of the possible risks
Concerns have been raised that the policy will discourage reporting2 but in Minnesota reporting has increased.4; The statutory requirement for reporting may mitigate this risk.
Some ‘never events’ may not be entirely preventable.2 There is concern that the policy may discourage settings from offering care for complex cases.5 In the US, many hospitals have adopted the policy voluntarily, and the policy has been taken up earlier by hospitals with better patient safety systems, suggesting that hospitals view the policy as requiring strong patient safety systems rather than as being unfairly punitive.6
Implications for health and well-being
There were 111 ‘never events’ reported to the National Patient Safety Agency in 2009/10.1Although serious, these events are rare and the public health impact of eliminating ‘never events’ would be low. ‘Never events’ may raise the profile of patient safety and strengthen patient safety systems. An estimated 10% of hospital stays lead to adverse events, of which around half are preventable.7 A ‘never events’ policy that improves patient safety has the potential to benefit all users of healthcare services, however scientific evidence to support the effectiveness of this policy is currently minimal.
Author: Helen Woodward BM BCh, Academic Clinical Fellow Public Health, London School of Hygiene and Tropical Medicine
UK area affected: England only
Appendix
NHS ‘Never events’ established in 2009
Minnesota Department of Health (2009) Adverse Health Care Events Reporting System: What have we learned? 5-Year review. http://www.health.state.mn.us/patientsafety/ae/09aheeval.pdf
1. National Patient Safety Agency (2010) Never Events Annual Report 2009/10. http://www.nrls.npsa.nhs.uk/resources/collections/never-events/?entryid45=83319
2. Department of Health (2011) The “never events” list 2011/12: Policy framework for use in the NHS. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_124580.pdf
3. National Quality Forum (20007) Serious Reportable Events in Healthcare 2006 Update: a consensus report. http://www.qualityforum.org/Publications/2007/03/Serious_Reportable_Events_in_Healthcare–2006_Update.aspx
4. Minnesota Department of Health (2009) Adverse Health Care Events Reporting System: What have we learned? 5-Year review. http://www.health.state.mn.us/patientsafety/ae/09aheeval.pdf
5. Teufack SG, Campbell P, Jabbour P, Maltenfort M, Evans J, Ratliff JK. Potential financial impact of restriction in “never event” and periprocedural hospital-acquired condition reimbursement at a tertiary neurosurgical center: a single-institution prospective study. J Neurosurg. 2010;112:249-56.
6. The Leapfrog Group (2008) More hospitals adopting leapfrog group’s “never events” policy which includes apologies, reporting, and waiving costs. Press release. http://www.leapfroggroup.org/media/file/NeverEvents2008.pdf Accessed 28 March 2011.
7. Department of Health Expert Group (2000) An organisation with a memory. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4065083
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