Never Events Overview:Fran Watts

Patient Safety Lead –Never Events

NHS Improvement and NHS England

Never Events Overview

• Definitions

• Overview

• Facts and figures- increases during COVID

• Role of Never Events team

• Grading of Never Events and Serious Incidents

• Review of grading wrong site surgery for dermatology

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Never Events are patient safety incidents that are wholly preventable where guidance or safety recommendations* that provide strong systemic protective barriers are available at a national level and have been implemented by healthcare providers.

Current definition of NE ‘barriers’

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CQC report - 2018

Recommendation:

NHS Improvement should work

with professional regulators and

royal colleges to review the

Never Events framework,

focusing on leadership and

safety culture, and exploring the

barriers to preventing errors

such as human behaviours.

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• The Never Events policy framework describes strong systemic protective barriers as:

➢ physical barriers (e.g. equipment that makes it impossible to connect medications via the wrong route); time and place barriers (e.g. withdrawal of concentrated medications from settings to prevent them being accidentally selected) or systems of double or triple checking where these are supported by visual or computerised warnings, standardised procedures or memory/communication aids. As all human action is vulnerable to human error, particularly where there is a risk of staff becoming overloaded, processes that rely solely on one staff member checking the actions of another or referring to written policies are not strong barriers.

Strong systemic safety barriers

Presentation title

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List of Never Events by frequency of actions needed to prevent them

Procedural safety requirements that require

consistent action by humans

Wrong-site surgery

Wrong implant/prosthesis surgery

Retained foreign objects

Administration of medication by the wrong route

Overdose of insulin due to abbreviations or incorrect

device

Overdose of methotrexate for non-cancer treatment

Transfusion or transplantation of ABO-incompatible

blood components or organs

Misplaced naso- or orogastric tubes

Scalding of patients

One-off actions required with infrequent

checks

Mis-selection of a strong potassium solution

(solution should not be readily available)

Failure to install functional collapsible shower or

curtain rails

Falls from poorly restricted windows

One-off actions required

Chest or neck entrapment in bed rails

Unintentional connection of a patient requiring

oxygen to an air flowmeter

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BEFORE AFTER

Some Never Events are about designing out the error (‘act once’)

Human factors engineering – understand what is leading to error/harm and change the equipment, not the human

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• Conducting a review of the Never Events list to explore the strength of the barriers for each Never Event

• Where there are numerous sub types to the Never Event, for example the three surgical Never Events, identifying the top five most frequently occurring:

➢Wrong site surgery – wrong tooth removal, wrong site block, wrong eye injections, wrong side spinal injections and wrong skin lesions

➢Wrong implant/ prosthesis – lens, hip, knee, IUCD and stents

➢Retained foreign objects post procedure -

NHSI response to the CQC recommendation

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Initial review of barrier strengths

Presentation title

Barrier type Explanation/examples

Examples of barriers

applicable to Never

Events

Level

Elimination

e.g. the discontinuation of the use of iopidine eye drops in children under 6 months

old; the removal of all solid organ perfusion fluids from hospitals without transplant

units.

Unintentional connection

of a patient requiring

oxygen to an air

flowmeter - removal of air

flowmeters

Very strong

Substitution

e.g. substituting the use of superabsorbent polymer gel sachets with polymer gel

pads for in clinical areas where vulnerable patients may be at risk of swallowing the

granules.

Overdose of high-

strength midazolam –

supply only low-strength

midazolam

Strong

Redesign and

engineering

controls

Redesign the work environment to prevent or limit access, standardise equipment

or processes; e.g. to reduce the risk of confusion between solid organ perfusion

fluids and other fluids in hospitals with transplant units the storage of solid organ

perfusion fluids in separate locked cupboard with keys held only by specialist

transplant staff

Unintended

administration of

concentrated potassium

chloride – very restricted

access to concentrate in

pharmacy only, special

locked compartment

Moderately

strong

Administrative

and

behavioural

controls that

are appropriate

to the error

type

For knowledge or rule based-errors: restricting a procedure to specific skilled staff,

education packages, competency-based frameworks, supervision and training,

senior review, point of use warnings, reminders, information, easy reference guides

For slips and lapses: eliminating or reducing distractions, providing memory aids,

better visual distinction between items that could be confused, separate storage

For routine violations: changes that make the desired action easier to do (e.g. hand

sanitising gel at every bedside, filtered giving set packaged with IV phenytoin)

Wrong side (laterality)

general surgery – site

marking, cross-checking

consent forms and

wristband with theatre list,

x-ray, checklist, time out,

etc.

Moderate

General

behavioural

controls

Campaigns to encourage personal behaviour change (e.g. clean your hands)

Encouraging staff to take breaks/maintain hydration

Encouraging staff to ask for help when uncertain

Wrong eye Lucentis

injection – verbal

confirmation of patient

name, no wristband, no

formal procedure list, no

second person for

checklist or time out

Weak

Token controlsUrging staff to be vigilant; writing policies and procedures without practical

implementation Very weak

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Collaboration with experts from the relevant medical royal colleges and other organisations with an interest in Never Events.

Three questions:

➢ Are the barriers for this Never Event strong enough to prevent it?

➢Are there any barriers currently that have not been considered?

➢Can any new barriers be developed to them from happening?

➢

Focus groups

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Wrong skin lesion biopsy/ removal is a sub type of Wrong Site Surgery Never Event

Wrong site surgery

An invasive procedure performed on the wrong patient or at the wrong site (eg wrong knee, eye, limb). The incident is detected at any time after the start of the procedure.

Includes: Interventions that are considered to be surgical but may be done outside a surgical environment – for example, wrong site block (including blocks for pain relief), biopsy, interventional radiology procedure, cardiology procedure, drain insertion and line insertion (eg peripherally inserted central catheter (PICC)/ Hickman lines).

Excludes: • removal of wrong teeth • local anaesthetic blocks for dental procedures (exclusion added May 2019) • interventions where the wrong site is selected because the patient has unknown/unexpected anatomical abnormalities; these should be documented in the patient’s notes • wrong level spinal surgery* • wrong site surgery due to incorrect laboratory reports/results or incorrect referral letters • contraceptive hormone implant in the wrong arm.

Wrong skin lesion biopsy/ removal definition

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Year Number of wrong skin lesions that are removed/ biopsied

2015/16 19

2016/17 16

2017/18 15

2018/19 22

2019/20 16

2020/21 32

Removal/ biopsy of wrong skin lesions data

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Where the lesions are Number

Back 15

Nose 7

Ear 2

Scalp 2

Thigh 1

Neck 1

Chest 1

Cheek 1

Not known 2

Total 32

Location of skin lesions – 2020/21

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• The patient called to say that they had a minor op procedure to remove a mole from their back and on returning home, their partner informed her that the wrong mole had been removed. She contacted the department and was advised to attend for review

• The patient was scheduled to attend an appointment for excision of a biopsy proven basal cell carcinoma on the right side of the nose. The patient attended their outpatient appointment , however the procedure was carried out on the left side of the nose. Awaiting biopsy results and the Consultant will be reviewing the patient in outpatients.

• A patient with Atypical Mole Syndrome, was seen in the dermatology clinic and 5 moles were identified for removal. The 18 week team (team undertaking the surgery) then saw the patient for removal of 3 moles from her thighs (2 from the right and one from the left). Three moles were removed however when the patient was reviewed prior to having the other 2 moles removed, it was noted that the numbering on the photos did not match the body map/ healthcare records and as a result the moles that were removed were not all the correct ones and wrong site surgery had occurred. The patient has now re-attended for removal of the intended moles.

Examples of incident reports

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Role of the national patient safety team –the challenge of safe care

How we support you to keep your patients safe

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NHS England » Our National Patient Safety Alerts/

NHS England » Patient safety review and response reports

Your incident reports help us and our

partners make a difference….

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We will continue to systematically review the list of Never Events to explore which sub types of Never Events do not meet the definition of a Never Event and could potentially be removed from the list.

Next steps for the Never Events review

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Questions?