If they are ‘Never Events’, why are they happening so often?

Never Events are serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations. The Never Events policy and framework – revised January 2018 suggests that Never Events may highlight potential weaknesses in how an organisation manages fundamental safety processes. Never Events are different from other serious incidents as the overriding principle of having the Never Events list is that even a single Never Event acts as a red flag that an organisation’s systems for implementing existing safety advice/alerts may not be robust. – NHS

The common malpractice in this stretch of time was surgery performed on the wrong part of the body. The records reveal how one patient had their ovaries removed when the surgical plan was to conserve them, another patient underwent surgery on the wrong eye and others had skin tags and haemorrhoids removed when another surgery was planned.

According to the NHS, the release of this list is not to encourage a ‘blame culture’, but rather to acknowledge red flags, highlighting when an organisation’s systems for implementing existing safety alerts may not be up to standard.

When a never event occurs, the organisation concerned must investigate and compile a report on what happened. Even when practised, medicine is not a zero-harm or a zero-risk profession. Preventable things can and do go wrong, sometimes with severe consequences to patients and the distress of the healthcare professionals involved.

Patients who have suffered harm because of a medical error should expect that what happened to them has been the subject of a thorough investigation to determine what happened, why and what lessons will be learned.

Organisations have no standard approach to investigating serious harm, so they miss valuable opportunities to understand why it happened – and crucially, how to stop it from happening again. Eva gives an organisation the power to put into timely practice the lessons arising from an event. Eva adds value to the review process. It brings together all relevant factors and analyses them with powerful AI to build a comprehensive picture of an incident.

The benefit of consolidating individual and team learning under expert facilitation is that you can make practical changes without waiting for the outcome of a full investigation.

The result is rapid improvement in patient safety.

Eva is a form of powerful patient safety technology. If you would like to learn more about Eva and how it can improve patient safety within your organisation, you can book a free 30-minute consultation with Eva’s founder, Ed Marsden, here. Alternatively, send us an email at [email protected].

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