Never Events
Regional Representatives Conference
17th November 2016
RCS London
Andrew Miles
DPA for South Central
Consultant Surgeon Winchester
2008 - High Quality Care for All
Healthcare is not a privilege to be
purchased but a moral right secured for all
Gordon Brown
On it’s 60th birthday
The NHS is in good health
Alan Johnson
Our NHS Secured today for future generations
Lord Darzi
‘Never Events’ introduced to the NHS
High Quality Care for All; Section 3: Para 56
“In some parts of the United States, events that are serious and largely
preventable such as ‘wrong-site’surgery have been designated ‘Never
Events’, and payment withheld when they occur. The NPSA will work with
stakeholders in this country to draw up its own list of ‘Never Events’.”
Never Events NPSA 2009
“Never Events are serious, largely preventable patient
safety incidents that should not occur if the available
preventative measures have been implemented by
healthcare providers.”
“A Never Event may or does result in severe harm or
death”
“There is evidence that the Never Event has occurred”
The original 8 events
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•
•
•
•
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Wrong site surgery
Retained instrument post-operation
Wrong route administration of chemotherapy
Misplaced oro/nasogastric tube not detected prior to use
Inpatient suicide using non-collapsible rails
Escape from within the perimeter of medium or high secure
mental health services by patients who are transferred from
prison
• In-hospital maternal death from post-partum haemorrhage
after elective caesarean section
• Intravenous administration of mis-selected concentrated
potassium chloride
Never Event List
• 2009-10
• 8 events “largely preventable”
• 2010-11
• 14 events now added errors in prescribing and incompatible
transfusion
• 2011-12
• 25 events now including wrong implant
• 2012-13
• Same 25 events but now described as “unacceptable and
eminently preventable”
• 2013-14
• Same 25 events but now retained foreign object post procedure
• 2015-16
• Reduced to 14 events but includes the three main surgical events
• 2016-7
• Same 14 events now part of NHS improvement and “wholly
preventable”
The 25 events
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•
•
•
•
•
•
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•
•
•
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Wrong site surgery
Wrong implant/prosthesis
Retained foreign object post-operation
Wrongly prepared high-risk injectable
medicine
Maladministration of a potassiumcontaining solution
Wrong route administration of
chemotherapy
Wrong route administration of
oral/enteral treatment
Intravenous administration of epidural
medication
Maladministration of insulin
Overdose of midazolam during
conscious sedation
Opioid overdose of an opioid-naive
patient
Inappropriate administration of daily oral
methotrexate
•
•
•
•
•
•
•
•
•
•
•
•
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Suicide using non-collapsible rails
Escape of a transferred prisoner
Falls from unrestricted windows
Entrapment in bedrails
Transfusion of ABO-incompatible blood
components
Transplantation of ABO-incompatible
organs as a result of error
Misplaced naso or oro-gastric tubes
Wrong gas administered
Failure to monitor and respond to
oxygen saturation
Air embolism
Mis-indentification of patients
Severe scalding of patients
Maternal death due to post partum
haemorrhage after elective caesarean
section
The current 14 events
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•
•
•
•
•
Wrong site surgery
Retained object post-procedure
Wrong route administration of medication
Mis-selected of strong potassium containing solution
Misplaced oro/nasogastric tube not detected prior to use
In-patient [attempted or] suicide and failure to install
collapsible rails
•
•
•
•
•
•
•
•
Wrong implant or prosthesis
Falls from poorly restricted windows
Chest or neck entrapment in bed rails
Overdose of insulin
Overdose of methotrexate
Mis-selection of high strength midazolam
Incompatible ABO transfusion or transplant
Scalding of patients by water for bathing or washing
Never events – The big 3
160
140
120
100
Retained foreign object
80
Wrong implant
Wrong site surgery
60
40
20
0
2009
2010
2011
2012
2013
2014
2015
2016
Never events – The big 3
160
?
140
120
100
Retained foreign object
80
Wrong implant
Wrong site surgery
60
40
20
0
2009
2010
2011
2012
2013
2014
2015
2016
Most frequent events 2014-5
• Wrong site surgery 124
• Wrong tooth 27
• Wrong skin lesion 14
• Wrong spinal level 12
• Wrong implant 102
• Lens 18
• Hip prosthesis 12
• Knee prosthesis 8
• Retained foreign object 40
• Vaginal swab 36
• Surgical swab 19
• Guide wire 15
2014-5 All Never Events 306
Why do they occur?
• Swiss Cheese theory of multiple failures
• It is rarely a single event
• Poor team structure
• Human factors
• Poor safety culture
• Excessive workload
• Lack of pre-operative infrastructure
• Changes to the order of the list during the list
• Emergency cases interrupting lists
• Multi-tasking by the staff involved with the procedure
• Distractions
• Interruptions during the procedure
• Personal life events
Sentinel events or random events?
• Professor Danny Keenan, CQC
“It remains to be seen if the list contributes importantly to safety. From
CQC’s point of view, never events are the tip of the iceberg. The iceberg is
the Trust’s overall approach to safety”
• Dr Michael Devlin, MDU
“Rather than focus on an arbitrary list of never events, which serve no one
and distort public perceptions, the NHS would be better to focus on
implementing initiatives that are proven to work to help improve patient
safety.”
• Moppett & Moppett
“Never Events …. are apparently random events they are the wrong metric
to gauge safety within the operating theatre”.
Anaesthesia 2016;71:17-30
Surgical Caseload and the risk of
never events
Why are UK figures for events not falling?
• Greater awareness and willingness to report
• duty of candour that the college has done has been instrumental
in surgeons becoming more transparent in everything from the
consent process to acknowledging and apologising when
mistakes have been made
• Checklists alone may not be the answer
• Checklists have probably made a difference but this difference is
offset by more accurate reporting of never events.–
• team training and awareness of human factors will provide
further gains but occasionally
• Swiss Cheese model of rare event occurrence
• If an event is repeated enough times then eventually anything
that can go wrong will go wrong
The next steps
• NatSSIPS
National Safety Standards for Invasive Procedures
• LocSSIPS
Local Safety Standards for Invasive Procedures
NatSSIPS
National Safety Standards for Invasive Procedures
• To apply to all invasive procedures:
• All surgical and interventional procedures performed in operating
theatres, outpatient treatment areas, labour ward delivery rooms, and
other procedural areas within an organisation.
• Surgical repair of episiotomy or genital tract trauma associated with
vaginal delivery.
• Invasive cardiological procedures
• Endoscopic procedures
• Interventional radiological procedures
• Thoracic interventions such as the insertion of chest drains
• Biopsies and other invasive tissue sampling
LocSSIPS
Local Safety Standards for Invasive Procedures
• PoIicies drawn up locally to reflect local implementation
of national standards
• Trust Boards or equivalent, shall be ultimately responsible for the creation
of LocSSIPs and their implementation
• Organisations should work with commissioners to “determine an
appropriate level of detail for records that will support audit and
investigation while not placing an intolerable burden upon procedural
teams.”
• LocSSIPs are to be “introduced and managed within a culture of
openness and transparency in which any member of any procedural team
knows that they can speak up to express concerns about the process or
patient safety at any time in the patient or procedural pathway”.
• “The patient is the most important member of the team” It is
recommended that patients be involved in the “creation, development,
implementation, review, modification and governance of LocSSIPs”
• Patients should participate in “the time out, sign out and other handovers
within the patient pathway”
Record keeping
FAQ – answers for regional
representatives
Is/are the WHO stop check/NatSSIPS/LocSSIPS mandatory?
Yes - The WHO check is mandatory and has now been extended to other interventions
using NatSSIPs and LocSSIPs.
Do they reduce incidents?
That is impossible to say a reduction of 1:20,000 to 1:30,000 could only be demonstrated
with a sample size of 6 million interventions, smaller improvements would require even
larger sample sizes to reach statistical significance.
What is the college position on their use?
Mandatory – but now that all Trusts are complying with their use team engagement with
the process is more important.
What other measures should surgeons deploy to reduce surgical never events?
There is a great deal of work being done on team training to empower all members of the
team to be involved with the process. Human factors analysis is central to understanding
why never events can still occur even after all the process has been correctly followed .
Can technology play a part?
Bar coding patients is used in some hospitals for blood transfusion to prevent errors.
Summary
• Never events still occur even where the
process has been followed by a fully
engaged team
• Never events are only part of a much wider
safety agenda
• Never events are not necessarily sentinel
events
Conclusions
• Surgeons will make mistakes
• Most mistakes can be prevented by a
cohesive team
• As professionals we must take
responsibility
Just last month ….
Hospital faulted for removing wrong patient’s kidney
By Liz Kowalczyk Globe Staff October 14, 2016
A surgeon at Saint Vincent Hospital unnecessarily removed a patient’s
kidney because he relied on the test results of another patient with the
same name, according to public health inspectors who found serious
safety lapses at the hospital.