Introduction:
Patient safety is a critical aspect of the healthcare system in the UK. Medical professionals strive to provide the highest quality care to their patients, but there are certain mistakes that can have devastating consequences. These events, known as “never events,” are entirely preventable and should never occur in medical practice. In this article, we will explore the never-event list in the UK, what it entails, and how it impacts patient safety.
What is the Never Event List?
The never-event list is a comprehensive list of events that should never occur in medical practice. These events are preventable, and if they do occur, they can have serious consequences for patients. The never-event list was first introduced in the US in 2001, and in the UK, it was developed in 2009 by the Department of Health.
The never-event list is regularly reviewed and updated to ensure it reflects the latest developments in medical practices. Currently, there are 15 events on the UK never event list, and these events are categorised into seven groups: See more here
- Surgical
- Medication
- Mental health
- Maternity
- Falls
- Pressure ulcers
- Diagnostic errors
Let’s explore each of these groups in more detail.
Surgical Never Events
Surgical never events are events that should never occur during a surgical procedure. These Never Event List include:
- Wrong site surgery
- Wrong implant/prosthesis
- Retained foreign object post-procedure
- Intraoperative/postoperative death in an ASA 1 patient
- Misplaced naso or oro-gastric tubes
Wrong-site surgery is the most common surgical Never Event List, and it occurs when a procedure is performed on the wrong part of the body. For example, operating on the wrong leg or performing surgery on the wrong side of the brain. These events can have severe consequences for patients, and they can lead to physical and psychological trauma.
Medication Never Event List
Medication-Never Event List are events that should never occur during the mediation process. These events include:
- Wrong route administration of chemotherapy
- Intravenous administration of epidural medication
- Maladministration of potassium-containing solutions
- Overdose of midazolam during conscious sedation
- Opioid overdose due to a transcription error or incorrect preoperative dose
Medication errors can have significant consequences for patients. For example, administering the wrong medication can lead to adverse drug reactions, while an overdose can lead to respiratory depression and potentially death.
Mental Health Never Event List
Mental health never events are events that should never occur during mental health treatment. These events include:
- Suicide using non-collapsible rails
- Escape of a transferred prisoner
- Abscond from low secure/unit with unauthorised absence
- Hanging using door handles or window fittings
- Attempted or actual murder/assault by patients with psychosis who have been assessed as high risk
Mental health Never Event List can have severe consequences for patients, their families, and the wider community. These events can lead to physical harm, psychological trauma, and loss of life.
Maternity Never Events
Maternity Never Event List are events that should never occur during childbirth or pregnancy. These events include:
- Maternal death due to postpartum haemorrhage
- Death or severe brain injury of a baby due to intrapartum hypoxia
- Wrong site block
- Severe perineal tears following childbirth
- Inability to ventilate a newborn during resuscitation after birth
Maternity never events can have significant consequences for both the mother and the baby. These events can lead to physical and psychological trauma, long-term.
Falls Never Event List
Falls never events are events that should never occur as a result of a fall or slip in medical care settings. These events include:
- Falls from poorly restricted windows
- Falls from unrestricted balconies
- Falls from inadequate bed rails
- Falls from chairs
- Falls from toilets
Falls can have severe consequences for patients, particularly those who are elderly or have existing medical conditions. These events can lead to fractures, head injuries, and psychological trauma. More about Never events in NHS
Pressure Ulcers Never Event List
Pressure ulcers never events are events that should never occur as a result of poor pressure ulcer prevention or management. These events include:
- Development of new pressure ulcers in patients who are not at high risk
- Development of new Category 3 and 4 pressure ulcers in high-risk patients
- Pressure ulcers in the community that result in death or serious harm
- Pressure ulcers acquired in the hospital that result in death or serious harm
Pressure ulcers can have significant consequences for patients, particularly those who are elderly or have existing medical conditions. These events can lead to infections, sepsis, and prolonged hospital stays.
Diagnostic Errors Never Event List
Diagnostic errors never events are events that should never occur as a result of misdiagnosis or delayed diagnosis. These events include:
- Wrong site radiotherapy
- Misidentification of patients
- Failure to act on or appropriately follow up diagnostic test results
- Failure to diagnose and appropriately manage sepsis
- Inadequate assessment and management of patients with fractures of the neck of the femur
Diagnostic errors can have significant consequences for patients, particularly those with life-threatening conditions such as sepsis. These events can lead to delayed treatment, prolonged hospital stays, and potential death.
Impact of Never Event List on Patient Safety
Never events are entirely preventable, and their occurrence indicates a failure in the healthcare system. These events can have severe consequences for patients, including physical harm, psychological trauma, and loss of life. Never events can also have financial implications for healthcare organisations, including the cost of litigation and compensation payouts.
To prevent never events, healthcare organisations must implement robust policies and procedures, educate their staff, and foster a culture of safety. Healthcare professionals must also report never events when they occur, and organisations must conduct thorough investigations to identify the root cause and implement corrective actions.
Conclusion
Never Event List-Patient safety is a critical aspect of the healthcare system in the UK, and never events should never occur in medical practice. The never-event list is a comprehensive list of events that should never occur, and it includes surgical, medication, mental health, maternity, falls, pressure ulcers, and diagnostic errors. Never events can have severe consequences for patients, and healthcare organizations must implement robust policies and procedures to prevent their occurrence. By prioritizing patient safety and fostering a culture of safety, healthcare professionals can work together to never prevent events and provide the highest quality care to their patients. Check my blog