Introduction:
Medical errors are an unfortunate reality in healthcare systems across the world. Despite rigorous training and procedures in place, healthcare providers sometimes make mistakes that can result in serious harm or even death to patients. However, some errors are considered to be completely preventable and should never happen in a healthcare setting. These events are known as ‘Never Events’, and their occurrence is seen as a serious failure of the healthcare system. This article aims to provide a comprehensive guide to Never Events in medical practice, specifically in the UK.
What are Never Events?
Never Events are defined as serious, preventable incidents that should never occur in a healthcare setting. The term ‘Never Event’ was first introduced in the UK in 2009 by the National Patient Safety Agency (NPSA) and has since been adopted by many other countries. These events are categorized into a list of 15 specific incidents that can cause severe harm or death to patients if they occur. Some examples of Never Events in Medical include:
- Wrong site surgery
- Retained foreign objects after surgery
- Administering medication to the wrong patient
- Misuse of oxygen or other gases
- Falls from poorly restricted windows or balconies
In the UK, the list of Never Events in Medical is updated annually to include new events or amend existing ones, ensuring that healthcare providers are aware of the latest developments. More about Never Events Claims.
Why are events never important?
Never Events are considered a serious failure of the healthcare system because they are preventable. They are not the result of an unpredictable complication or a medical condition that is difficult to manage but rather a failure to follow established protocols and procedures. In addition to causing harm to patients, Never Events in Medical also result in increased healthcare costs, legal action, and damage to the reputation of healthcare providers and organizations.
Reporting and Investigating Never Events in Medical:
When a Never Event occurs, healthcare providers are required to report the incident to the relevant authorities, such as the Care Quality Commission (CQC) in the UK. This reporting process ensures that the incident is investigated thoroughly and steps are taken to prevent similar incidents from occurring in the future. Additionally, healthcare providers must also inform the affected patient and their family of the event, apologize, and offer support and compensation if necessary.
Preventing Never Events in Medical:
Preventing Never Events requires a multi-faceted approach that involves a combination of training, protocols, and technology. Healthcare providers must undergo rigorous training to ensure that they are aware of the latest procedures and protocols and understand the importance of following them. Additionally, technology such as barcode scanning systems can be used to ensure that medication is administered to the correct patient, reducing the risk of errors.
The Role of Patients:
Patients also have an important role to play in Never preventing Events. Patients should be informed and involved in their care and encouraged to ask questions and raise concerns if they feel that something is not right. Additionally, patients should be provided with clear information about their medications and advised to bring a list of their current medications to every appointment.
Examples of Never Events in Medical in the UK:
The list of Never Events in the UK includes 15 specific incidents, which are reviewed and updated annually. Here are some examples of Never Events that have occurred in the UK:
Wrong site surgery:
In 2018, a patient underwent surgery on the wrong side of their body at a hospital in London. The incident was caused by a breakdown in communication between the surgical team and the patient, resulting in the wrong site being marked for surgery. The hospital reported the incident to the CQC and undertook a review of its protocols to prevent similar incidents from occurring in the future.
Medication errors:
In 2017, a patient in a UK hospital was given an overdose on a chemotherapy drug due to a medication error. The error occurred when the wrong dose was prescribed, and the medication was not checked by a second healthcare professional. Never Events in Medical-The hospital reported the incident to the CQC and implemented additional checks to ensure that medications were correctly prescribed and administered. Check my blog
Misuse of oxygen or other gases:
In 2019, a patient in a UK hospital suffered a cardiac arrest after being given pure oxygen instead of air during a surgical procedure. The incident occurred due to a failure to correctly label the gas supply, resulting in the wrong gas being administered to the patient. The hospital reported the incident to the CQC and undertook a review of their labelling procedures to prevent similar incidents from occurring in the future.
Preventing Never Events in Medical in the UK:
Preventing Never Events in the UK requires a comprehensive approach that involves healthcare providers, patients, and regulatory bodies. Here are some strategies that can be used to prevent Never Events:
Education and training:
Healthcare providers must undergo rigorous training to ensure that they are aware of the latest protocols and procedures and understand the importance of following them. This includes training on communication, teamwork, and patient safety.
Protocols and procedures:
Healthcare organizations must have clear protocols and procedures in place to prevent Never Events in Medical. These protocols should be regularly reviewed and updated to ensure that they reflect the latest best practices.
Technology:
Technology can be used to reduce the risk of Never Events in Medical by ensuring that medications are correctly prescribed and administered and that patient identification is accurate. This includes the use of barcode scanning systems and electronic health records.
Patient involvement:
Patients should be involved in their care and encouraged to ask questions and raise concerns if they feel that something is not right. This includes being provided with clear information about their medications and advised to bring a list of their current medications to every appointment.
Conclusion:
Never Events in Medical are preventable incidents that should never occur in a healthcare setting. They are a serious concern in the UK healthcare system, and their occurrence is a failure of the healthcare system. Preventing Never Events requires a multi-faceted approach that involves healthcare providers, patients, and regulatory bodies. By working together, we can ensure that Never Events in Medical become a thing of the past and that patient safety is prioritized in all healthcare settings. For more about click here.