Never Events: analysis of HSIB’s national investigations
Following a detailed analysis of 10 investigations, this report states that Never Events should not be defined as such if they don’t have strong enough barriers in place to stop them happening, and recommends 7 on the current list of 15 be removed until these are in place.
Source:
Healthcare Safety Investigation Branch
SPS commentary:
Never Events are defined as patient safety incidents that are wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and have been implemented by healthcare providers. The patient safety incidents in the investigations reviewed in the report cover the 7 areas accounting for 96% of the Never Events recorded in 2018/19. The Healthcare Safety Investigation Branch recommends that NHS England and NHS Improvement: 1) revises the Never Events list to remove events, such as those presented in this national learning report, that do not have strong and systemic safety barriers; and 2) develops and commissions programmes of work to find strong and systemic safety barriers for specific incidents where barriers are felt to be possible but are not currently available.