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A new report sets out a number of recommendations on how ‘never events’ can be eliminated from NHS surgery. Dr Mike Durkin, NHS England’s Director of Patient Safety, explains the key recommendations and the next steps to them action across the NHS:
Never events are exactly what they say they are – events that should never happen because there are evidence based interventions to prevent them.
In the context of the 4.6 million hospital admissions that lead to surgical care each year in England, these events are rare. However, each and every never event is one too many.
From looking at the numbers of reported never events we have recognised the number of these incidents has remained relatively constant. This indicates the current preventative tools and guidance, particularly for surgical never events, have not been effective. To help us understand why, and to provide guidance on what more can be done, in April 2013 we commissioned a Surgical Never Events Taskforce, on which sat a range of experts, to lead work to develop recommendations for action to eradicate surgical never events.
Today we have published the findings of the taskforce, and the NHS England Patient Safety Domain has already begun work to consider how the recommendations can be put into practice. These recommendations will now be built on to support NHS staff across England to eliminate never events from the operating theatre environment.
To summarise the report, the recommendations focus on three themes:
- Standardise – The development of national standards of operating department practice that will support all providers of NHS funded care to develop and maintain their own, more detailed, standardised local procedures. The report also recommends the establishment of an Independent Surgical Investigation Panel to externally review selected serious incidents;
- Educate – Consistency in training and education of all staff in operating theatres, development of a range of multimedia tools to support implementation of standards and support for surgical safety training including human factors; and
- Harmonise – Consistency in reporting and publishing of data on serious incidents, dissemination of learning from serious incidents and concordance with local and national standards taken into account through regulation.
In order to achieve our overarching goal to eradicate never events, we will need to engage and collaborate with organisations and bodies across the healthcare spectrum including patient groups, trusts, royal colleges, specialist societies, and regulators, to not only ensure the initiatives we develop are accessible and achievable, but also that they can be used as standard practice across NHS peri-operative care, education, training and regulation.
Key to all this will be the development and implementation of national standards on the prevention of surgical never events. To do this we will use established groups such as NHS England’s patient safety expert groups, and will establish new groups and networks to engage and consult.
These national standards will be overarching frameworks and high-level descriptions of what should constitute standard practice for various aspects of peri-operative procedures. The standards will be further developed locally to create standardised practices within organisations, on an organisation by organisation basis.
Our plan will also include the development of a range of resources to support the implementation of these local standards, including commissioning resources. To reach our aim it is also vital that we work to ensure the prevention of surgical never events becomes embedded in healthcare education and training.
We are certainly not starting from scratch on never events and previous preventative measures still remain current and valid. We recognise the importance of using existing learning from what has already been achieved, such as through the implementation of the WHO Surgical Safety Checklist.
Finally, I would like to personally thank each member of the taskforce for the hard work, commitment and dedication they put into producing this report; and I know they will all continue to help us drive the recommendations forward via their own organisations.
However, it is now time to take this important work to the next level, as we work with our staff, partners and stakeholders to turn the recommendations into actions and firmly instil them across NHS surgical care.