NHS England today (Thursday) publishes more detailed data than ever before about “never events” – the serious errors in care that put patients at risk of harm and that should not happen if full preventative procedures are in place.
For the first time, provisional quarterly data on the number of never events happening at each hospital trust in England will be published, for patients, healthcare professionals, managers, stakeholders and the public to see and understand. Until now, data has been published only annually, and only at national, aggregated level. The data is available on the NHS England website (as of 2017 the data now available on the NHS Improvement website), and will be updated in three months’ time. From April 2014, the data will be updated every month.
Professor Don Berwick, the US expert who earlier this year led a landmark review into patient safety in England, has hailed the publication as an admirable and important step.
Never events include such incidents as wrong-site surgery, items like swabs and other medical equipment being accidentally left inside a patient, and strong drugs like chemotherapy being administered in the wrong way.
The provisional data shows:
- 102 NHS trusts had at least one never event between April and September this year
- 8 independent hospitals had at least one never event between April and September this year
- There were 37 instances of wrong-site surgery in the six months from April to September, and 70 incidents of foreign objects being mistakenly left inside patients.
Not all never events result in serious harm to patients. Wrong-site surgery incidents, for instance, range from an incision being made in the wrong place at the beginning of surgery then instantly spotted and corrected, to the wrong tooth being removed, to very severe incidents like the wrong limb or organ being operated on. Information breaking down the types of incidents recorded is available on the website.
There are 4.6 million hospital admissions that lead to surgical care every year in England, and 500,000 non-Caesarian births. There are also tens of thousands of other interventional procedures like internal radiology and cardiology catheter procedures that are also classified as “surgical” in terms of never events. So the incidence rate is less than 0.005% or 1 never event in every 20,000 procedures.
The data shows that the number of never events recorded is broadly similar to last year. NHS England expects that reporting of these incidents will continue to increase as the NHS becomes a more transparent and learning system, and as the types of incidents that are classed as “never events” continue to increase in line with developments in patient safety practices.
Dr Mike Durkin, National Director of Patient Safety at NHS England, said: “Awareness in the NHS of these issues has never been greater and the quality of our surgical procedures has never been better. It follows that the risk of these things happening has never been smaller.
“Every single never event puts patients at risk of harm which is avoidable. People who suffer severe harm because of mistakes can suffer serious physical and psychological effects for the rest of their lives, and that should never happen to anyone who seeks treatment from the NHS.
“But is time for some real openness and honesty. There are risks involved with all types of healthcare. And one of those risks – with the best will in the world and the best doctors, nurses and other healthcare professionals in the world – is that things can go wrong and mistakes can be made. This has always been the case, and it is true everywhere in the world.
“This publication is not about ‘naming and shaming’ – it is about telling the public about mistakes, and further ensuring that we talk about and learn from them. That is the way to minimise errors and take every step we can to drive avoidable harm out of the NHS.
“By making this detailed data fully open to public scrutiny, we are fulfilling a key recommendation of the Francis Review, but more importantly we are making a big step towards further reducing these events. As Professor Don Berwick made clear in his report on patient safety earlier this year, these incidents can only be truly minimised if we talk about them in an open and honest way, and all work together to make sure every effort is being made to stop whatever went wrong from happening again.”
The NHS in England has made significant strides in improving patient safety in recent years, and its reporting and alert systems are credited as being some of the best in the world. But there is always more that can be done, and the safety and quality of care for NHS patients is a key priority for NHS England. Currently, further work is under way to develop new, easier-to-use reporting systems.
In addition, a Surgical Safety Task Force is undertaking an in-depth review of surgical never events and is due to report in the New Year, presenting even further insight into how we can make surgery safer across England.
Key proposals will focus on the adoption of a more systematic approach to surgical safety. This will include standardising operating theatre procedures, new standardised education and training, and work to ensure professional and organisational incentives support safe procedures and working cultures.
Professor Don Berwick said: “No one who works in any hospital wants to see patients come to any harm at all. When serious errors occur, it is a tragedy for both patients and staff, so the courage and commitment shown by the NHS in publishing this data are admirable.
“One way to help improve safety is by openly and honestly recognizing, discussing, and examining mistakes in care. That helps us create continually better systems and procedures.
“Blame and punishment have no productive role in the scientifically proper pursuit of safety. But openness and transparency do. They are the front door to learning and improvement. I applaud NHS England for this important step toward better knowledge and better support to both staff and patients.”