News

06.05.15

‘Never events’ at hospitals fall by nearly 10% – but 308 still happened

The number of ‘never events’ taking place at hospitals in England has fallen by nearly 10% over the last year.  

New figures published by NHS England show that between 1 April 2014 and 31 March 2015 a total of 308 ‘never events’ took place, compared to 338 the previous year, a reduction of 9%.

These are serious, largely preventable patient safety incidents that should not occur if the available guidance or safety recommendations have been followed.

Examples include ‘wrong site surgery’, where the wrong area of the body is operated on; a ‘retained foreign object post-procedure’; and the use of the wrong implant or prosthesis.

The provisional data for the last year provided by NHS England shows:

Type of Never Events

The most common type of ‘wrong site surgery’ was the wrong tooth or teeth being removed, followed by having the wrong skin lesion excised. The most common ‘retained foreign objects’ post-procedure were vaginal and surgical swabs.

Colchester Hospital University NHS Trust was found to be the worst performing, with nine ‘never events’ for the year. There were five cases of items being left inside patients, one wrong implant and three wrong site surgery cases.

The trust also had 420 "serious incidents" in the past year.

A spokesman for Colchester Hospital University NHS Trust said: "High reporting of incidents is viewed positively because it shows an organisation encourages transparency and learning.

"The trust, therefore, proactively encourages all staff to be open and to report incidents and has a 'no blame' policy so learning can take place to prevent recurrence.

"Incidents are reviewed on a daily basis by an executive director-chaired panel that determines immediate action which needs to be taken to prevent recurrence and to safeguard the welfare of patients."

The other poorly performing trusts were King’s College Hospital NHS Trust with eight ‘never events’; Mid Essex Hospital Services and University Hospitals Bristol NHS Trusts on seven; followed by Guy’s and St Thomas’, Queen Elizabeth Hospital Kings Lynn, Oxford University Hospitals and Wrightington Wigan and Leigh all on six.

Tell us what you think – have your say below, or email us directly at [email protected]

Comments

Alex Grice   07/05/2015 at 10:50

Never events will always happen which is why the name is misleading - anyone with a basic understanding of system theory will be able to explain why. Sadly the latest framework states that 'They are wholly preventable, where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level' which shows how misguided NHSE is on this subject. Politicians love Never Events as it gives them a headline but in reality they prove more detrimental to the staff involved than anyone outside the organisation realises. The value of naming Colchester? Nil really, just gives a good hospital a bad tabloid heading and adds to their challenges. We should drop never events, we have a SIRI framework that will achieve the same improvements without them.

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