Never Events

1
Never Events

• Tanya Huehns
• Patient Safety Strategy Advisor
• NPSA

2
Never Events

• Concept originated
• from US
• Related to insurance
• Reported annually

3
Never Events

• Enshrined in law
• 27 events
• Surgical
• Care management
• Environmental
• Patient protection
• Product or device
• Criminal

4
Never Events
5
Never Events

• Darzi report
• High quality care for all

6
Never Events

• Criteria for a UK list
• Results in severe harm/death
• Evidence that occurred in the past
• Existing national guidance and/or national safety
  recommendations that advise on how to prevent,
  along with support for implementation
• Occurrence can be easily defined, identified and
  measured on an ongoing basis

7
Never Events

• Proposed list
• 1. Wrong site surgery
• 2. Retained instrument post-operation
• 3. Wrong route administration of chemotherapy
• 4. Misplaced naso or orogastric tube not detected
  prior to use
• 5. Inpatient suicide using non-collapsible rails
  or whilst on one-to-one observations
• 6. Absconding of transferred prisoners from
  medium or high secure mental health services
• 7. In-hospital maternal death from post-partum
  haemorrhage after elective Caesarean Section
• 8. IV administration of concentrated potassium
  chloride

8
Never Events

• What is the NPSA doing?
• Develop and consult on criteria, list and process
• Website and tools on systems to prevent and on
  root cause analysis
• Advice
• Evaluate
• Report
• Work on subsequent years

9
Never Events

• How will this potentially affect PCTs?
• Need to include in contracts
• Ensure themselves providers have systems in place
  to prevent and to Ix promotes discussions and
  action
• Measure
• Report

10
Never Events

• How will this potentially affect providers?
• Need to agree contracts
• Ensure themselves about their own systems to
  prevent and to Ix promotes discussions and
  action
• Measure
• Report

11
Never Events

• How will this potentially affect SHAs?
• Support commissioning
• Support local root cause analyses
• Communicate issues to NPSA

12
Never Events

• Next steps
• Feedback exercise during October finished
• Report out on revised process in late November
• Included in annual plans for 2009/10
• Tools etc available early 2009
• Live from April 2009
• Evaluation of first year
• Work on subsequent years

13
Never Events

• Thanks
• Any comments on process or list?
• Or send to me as soon as possible
• tanya.huehns_at_npsa.nhs.uk