Never events: what's on your list of ensuring patient safety?

I was talking about Never Events at a dinner party, trying to explain what they are, and two friends were horrified - at the concept that in healthcare we need to draw up a list of things that should never happen.  I agree, as a patient the list below does feel scary - not because they might happen, but because we need to talk about them not happening...


The NHS in England has just expanded the list to 26 from 8 (details are in this policy document); I'm still not sure whether this is a good thing or not.I have heard that some countries and regions don't bother with Never events lists. I'd be interested in finding out whether they do this for a reason.

There are 25 "never events" on the expanded list. This includes the original eight events from previous years, some of which have been modified, and builds on the draft list published in October 2010. The list is as follows:

1. Wrong site surgery (existing)
2. Wrong implant/prosthesis (new)
3. Retained foreign object post-operation (existing)
4. Wrongly prepared high-risk injectable medication (new)
5. Maladministration of potassium-containing solutions (modified)
6. Wrong route administration of chemotherapy (existing)
7. Wrong route administration of oral/enteral treatment (new)
8. Intravenous administration of epidural medication (new)
9. Maladministration of Insulin (new)
10. Overdose of midazolam during conscious sedation (new)
11. Opioid overdose of an opioid-naïve patient (new)
12. Inappropriate administration of daily oral methotrexate (new)
13. Suicide using non-collapsible rails (existing)
14. Escape of a transferred prisoner (existing)
15. Falls from unrestricted windows (new)
16. Entrapment in bedrails (new)
17. Transfusion of ABO-incompatible blood components (new)
18. Transplantation of ABO or HLA-incompatible Organs (new)
19. Misplaced naso- or oro-gastric tubes (modified)
20. Wrong gas administered (new)
21. Failure to monitor and respond to oxygen saturation (new)
22. Air embolism (new)
23. Misidentification of patients (new)
24. Severe scalding of patients (new)
25. Maternal death due to post partum haemorrhage after elective Caesarean  section (modified)

Publishing negative studies is good for learning

Humans learn by making mistakes. When the mistakes of others are hidden then we all have to go over the same ground to discover the errors - a waste of time, in many cases. The issue of publishing negative studies is a bit one.  When I was researching my book "Why good practice doesn't spread" I could find no-one who was prepared to share, publicly, their experience of a large scale change project that did not achieve what it set out to do. They would talk in private and anonymously - but not openly.

One of my ambitions is to start the online Journal of Quality Improvement and Patient Safety Program Failures. I would love to be able to read about projects that went pear-shaped. I think I would learn more from them than from the ones which advertise greatness.

If you have ideas on what should be included in this Journal then please leave a comment on this blogpost or email me directly.

In the meantime if you want to read a few articiples and papers about the issue check out:
Increased calls for publishing negative clinical trial data
Publish or perish culture distorting research results
The importance of publishing negative results

Is there evidence for your quality improvement intervention?

Is there evidence for the interventions we're using to improve quality of services and to reduce costs? I suspect in many cases there isn't. Sometimes just doing something is better than nothing, though I do find it surprising that some organisations are strong at pushing a particular intervention, even though there are few (unpaid for) independent evaluations. And on the other hand, there are some well evidenced interventions that organisations don't want to use because they are appear old fashioned. Hmmm - we demand of healthcare professionals that they use the best evidenced methods - should we be demanding that of ourselves?

There's an excellent visualisation for the scientific evidence of dietary supplements. When I looked at this I wondered whether we could do something similar for the quality improvement interventions that are being used around the world?

In the meantime, using the SQUIRE Guidelines to write up your projects will go a long way to building up an evidence base of what works - and what doesn't.

The Innovator's DNA - book by Dyer, Gregerson, Christensen

The Innovator's DNA; Mastering the five skills of disruptive innovators is a book that we really need - right now - as we try to rearrange public services so we reduce costs and improve quality. I hear many people talk innovation but few actually doing it. I also think there are many innovators hidden away in organisations; just because they aren't smart at advertising themselves doesn't mean their abilities shouldn't be harnessed. So be on the look out for the following:

1. Associating; innovators connect the dots and see patterns between seemingly unrelated topics, tasks and issues
2. Observing: innovators spot emerging trends long before the formal reviews because they are intense observers of the small details.
3. Experimenting; innovators try things out - they don't necessarily talk about it or spend their time encouraging others to do it - they test things out themselves
4. Questioning; innovators can be a pain in the rear because they are curious and because they like discovering new stuff
5. Networking; it's difficult to spot patterns, notice details and test things out unless you have buddies. Innovators are terrific networkers and often link with others outside what may appear to be "normal" interests. They are also involved with groups outside their employment.

How would you rate yourself on these five categories?

Social Media Policy: The simplest way forward

So many public sector organisations are still banning the use of social media. This seems a bit like being unwilling to give up your horse when the cars are all whizzing past you.  Anyway, the root of this short-sighted vision is often fear. Apart from fear of the unknown (when senior managers have no idea about social media they are more prone to ban it or poo-poo it) there is also the fear of lack of control. In the public sector we're good at writing rules and regulations so when management does get to grips with social media it tends to be via a tortuous and complicated social media policy.

I particularly liked Mike Brown's take on social media policies. He recommends the following (please go to his blogpost to read the whole article:

“Will what you’re about to share online offend, surprise, or shock your

• Spouse
• Mother
• Employer (current or future)
• Clients (current or future)
• Business partners (current or future)
• Coworkers
• Children

in a way which critically jeopardizes your relationship? If you answer even one “Yes” for this short list of people, think long and hard before publishing your content.”