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NHS England publishes Never Events Policy Framework Review consultation online
NHS England has strengthened its position as one of the safest and most transparent healthcare systems in the world by publishing the Never Events Policy Framework Review consultation.
The purpose of the consultation is make it is clearer as to what needs to be done, and by whom, to prevent never events. Part of the review will also consider financial penalties for never events, and how this might be included in the NHS Standard Contract for 2015/16.
The review is focusing on five key issues: the purpose, definition, list of, management, and application of learning from never events.
The reviewed draft framework will be available online at until 31 October 2014. Individuals are invited to provide their views using an online survey.
The overall aim of the review is to keep patient safety as a focus for action, and to foster a culture which aims to share learning and improve, rather than to blame and penalise.
Dr Mike Durkin, NHS England’s National Director of Patient Safety, said: “The key aim of this review and consultation is to make the Never Events Policy Framework as usable as possible, which will lead to better sharing of learning, and greater patient safety.
“I hope that everyone with an interest in improving patient safety will use this opportunity to give NHS England their views.”
The new wording of the never event for methotrexate will cause difficulties for a significant minority of patients receiving oral methotrexate for rheumatological conditions. Methotrexate is the first choice disease modifying drug (DMARD) for rheumatoid arthritis. Its efficacy is dose-related and many patients need 25mg weekly to acheive best response. Unfortunately, not all patients can tolerate 25mg as a single dose because of unpleasant, but not dangerous side-effects. There are two possible strategies for dealing with this. One is to switch to weekly subcutaneous methotrexate. Not all patients are prepared to self-inject and it is significantly more expensive. It doesn’t always lead to amelioration of the side effects. The other is to split the dose of methotrexate, taking it either on two consecutive days or several days apart. The rationale is that the side effects are related to peak serum levels of methotrexate, whereas efficacy is related to total weekly dose. Since the serum half life of methotrexate is short, levels falling to zero within 24 hours or so, patients are never exposed to high serum levels. There is no evidence that I am aware of that twice weekly methotrexate is any more toxic than once weekly, as judged by monitoring of blood parameters. Nor is it a stepping stone to inadvertant daily administration. Patients on twice weekly methotrexate identify the days on which they take the drug. These days are recorded in their monitoring booklets.
If this becomes a never event then patients will either have to switch to subcutaneous methotrexate, revert to once weekly and manage the side effects as best they can, reduce the dose (and therefore the efficacy) or add additional DMARDs to control their disease. None of these outcomes is acceptable. A careful rewording allowing for twice weekly dosing under specialist review would overcome this difficulty.
It’s a shame that we have removed medicines to wrong person from the list as that should be completely preventable/ avoidable and the reason given – current safeguards aren’t sufficient to stop it happening doesn’t seem like the best rationale.
Thank you for your comment on the Never Events Policy Framework review. NHS England welcomes feedback from individuals or organisations and will take your comment into account as part of the consultation process. We would also invite you to complete the whole survey if you have not done so already.