Article by Susan Mayor, published 25 February 2011

The NHS has extended the list of preventable events that should never happen during the care of patients by NHS services and introduced financial measures to penalise service providers when these events do occur. But critics have warned that it is not clear how these events will be reported and investigated and how the NHS organisation will learn from them.

The Department of Health announced that it is extending the “never events” list from eight in the previous list to 25. These are defined as very serious, largely preventable patient safety incidents that should not occur if health service providers have put appropriate preventive measures in place.

The new events added to the list include severe harm or death caused by misidentifying patients by failing to use standard wristband identification processes, severe harm or death due to transfusing the wrong type of blood, and severe scalding. Several relate to the incorrect use of drugs. The list was developed after consultation with the NHS, health professionals, the Royal Colleges, and the public.

Martin Bromiley, an airline pilot and chair of the Clinical Human Factors Group, a charitable trust that works with safety critical organisations, including the NHS, said, “The expanded never events list is important in that it should leave clinicians in no doubt about what incidents should be investigated.

“But the problem is that it is not clear how these events will be investigated and how others will learn when a never event occurs. If we don’t learn each time, it will be repeated.”

He added, “It is not currently clear who is going to drive the safety agenda in the NHS.” The National Patient Safety Agency, the organisation that has led the NHS in improving patient safety, is being abolished under the government’s halving of NHS quasi-autonomous national governmental organisations (BMJ 2010;341:c4074; doi: 10.1136/bmj.c4074).

Peter Walsh, chief executive of the charity Action against Medical Accidents, suggested that the Care Quality Commission, the NHS regulator, should be more proactive in monitoring compliance with the never events list and use its powers to take action against trusts who continually fail to comply.

The list of never events will be included in the NHS Standard Contract, meaning that payment from GPs or other commissioners can be withheld when they occur. This will cover the cost of the care episode in which the never event occurs, and, if appropriate, the cost of treating the consequences.

“The extended list includes avoidable incidents with serious adverse consequences for patients. No one wants these to happen, therefore we should not have to pay hospitals when these events occur,” said the NHS medical director Bruce Keogh. “This will send a strong signal to leaders of the organisation to learn from their mistakes so they don’t happen again.”

The Department of Health is recommending that commissioners and providers agree how the cost recovery process will work when drawing up contracts for services. It suggested a cap equivalent to one month’s inpatient stay, or about £10 000.

NHS organisations will have a statutory requirement to report all serious patient safety incidents to the National Reporting and Learning System, which analyses confidential reports of patient safety incidents from healthcare staff in England and Wales, and to the Care Quality Commission, the independent regulator of health and social care in England.

Mr Bromiley suggested that a full and independent investigation should be conducted each time a never event occurs, and the findings circulated to NHS staff so they can learn from what happened.

A total of 111 never events were recorded in 2009-10, with most being wrong site surgery and misplaced nasogastric tubes.

“Full investigation of these 111 never events could have provided a great deal of information to prevent them occurring again,” suggested Mr Bromiley.

The NHS’s previous focus on learning from “near misses” was ill conceived he said. “The big learning from the aviation industry is to investigate and learn from serious incidents, which gives frontline people the understanding of the factors contributing to their occurrence so they can then start to recognise near misses.”

The NHS never events list

Events on the previous list:

  • Wrong site surgery
  • Wrong route of administration of chemotherapy
  • Suicide using non-collapsible rails
  • Retained foreign object postoperation
  • Escape of a transferred prisoner
  • Events on the previous list, but now modified:

  • Maladministration of potassium containing solutions
  • Misplaced naso- or oro-gastric tubes
  • New events added to the list
  • Wrong implant/prosthesis
  • Wrongly prepared high risk injectable medication
  • Wrong route administration of oral/enteral treatment
  • Intravenous administration of epidural medication
  • Maladministration of insulin
  • Overdose of midazolam during conscious sedation
  • Opioid overdose of an opioid naïve patient
  • Inappropriate administration of daily oral methotrexate
  • Falls from unrestricted windows
  • Entrapment in bedrails
  • Transfusion of ABO incompatible blood components
  • Transplantation of ABO or HLA incompatible organs
  • Wrong gas administered
  • Failure to monitor and respond to oxygen saturation
  • Air embolism
  • Misidentification of patients
  • Severe scalding of patients
  • Maternal death due to post partum haemorrhage after elective caesarean section
  • BMJ 2011; 342:d1263 doi: 10.1136/bmj.d1263 (Published 25 February 2011)

    Cite this as: BMJ 2011; 342:d1263

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