Wednesday, 23 March 2011

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)

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