10 July 2013
Concern as a number of ‘Never Events’ are recorded in an NHS hospital
Would you want to be treated at a hospital with a high rate of recorded ‘never events’ - mistakes which should never happen? The Care Quality Commission recently paid an unexpected visit to Plymouth Hospitals NHS Trust and issued a warning after the Trust was involved in a number of never events - the second highest number in the country.
'Never events' include surgery in the wrong place, retained instruments and maternal deaths from bleeding after planned caesarean sections and a list of them as the NHS defines them are set out below. (They are defined more widely elsewhere, particularly in the USA and there are probably other events that should never happen.) Most negligent mistakes are from errors of judgment or administrative failings. 'Never events' are so called because there is just no excuse besides carelessness for them happening.
So would it put you off to know that your treating hospital had a high rate of recorded 'never events'? I am not sure it should. Reporting of errors is very patchy within the NHS. Some Trusts are far less open about their mistakes than others. Probably some departments within the same Trust are less open than others. Some investigations are thorough, producing well-researched and helpful ‘Serious Untoward Incident Reports’ which try to learn from mistakes. Some are not. High rates of 'never events' may be an indication of problems at the Trust. Or it could just be a sign that the Trust takes reporting more seriously than others. So as with all statistics we need to consider carefully how we interpret them.
There is certainly a need to avoid medical mistakes causing injury at all our NHS hospitals. But there is also a need to both openness and consistency across the board.
NHS Never Events
1. Wrong site surgery
2. Retained instrument post-operation
3. Wrong route administration of chemotherapy
4. Misplaced naso or orogastric tube not detected prior to use
5. Inpatient suicide using non-collapsible rails
6. Escape from within the secure perimeter of medium or high secure mental health services by patients who are transferred prisoners
7. In-hospital maternal death from post-partum haemorrhage after elective caesarean section
8. Intravenous administration of mis-selected concentrated potassium chloride.