Never events

There has been a lot of news about never events recently. Having been at the beginning when they were conceived I thought I would clarify a few things. 

The idea at the start was to have no more than 8 ‘events’ – a list of things that happened during the delivery of  care that really shouldn’t. 

Not simply a list of serious events but genuinely things that were felt could be eradicated if all the right barriers and systems were in place. That we could design equipment or processes that would make it impossible to make a mistake. Circumstances or events that fit this criteria are very rare but there are one or two. 
The list was carefully thought through. The idea (and this is crucial) was that after testing the list would be reduced to around 2 or 3. This was so that providers could then invest time, effort and resources to ensure they could put in place the mechanisms that would prevent them from happening. 

The rest of the ‘things that go wrong’ would be dealt with through the normal risk and safety processes already in existence in every provider.

In addition a concerted effort was made to say that the events should not be used to simply count or even worse blame. That they were seen as vital clues to help us continually learn and improve. 

Sadly this didn’t turn out to be the case. Instead:

  • The list got bigger and bigger
  • Organisations and individuals were blamed and made to fill out numerous forms for others to scrutinise
  • Never events became a tool to name and shame. Yet another league table

Put to one side those exceptionally rare individuals who do turn up to work to harm….

I have never met a fellow NHS health worker who meant to cause harm, who meant to make a mistake. 

In fact that’s the very heart of an error or mistake; the fact that it is unintentional. 

Questions are now being asked about whether the concept or title are right or wrong. Whether we should also have ‘ever events’ as well as ‘never’. 

What we really don’t want to lose is the chance to learn and the chance to put right. 

If never events are failing to do this core purpose and in fact leading to people fearful of reporting them then it may be braver to stop and start again. 

2020 vision

There are some new clues that will help us see more clearly about what is happening with patient safety at a national level…

The vision for 2020 via Mike Durkin via twitter is:

  • Increase our understanding of what goes wrong in healthcare i.e. capture incidents and learn from investigations at a national level – these are via the new Patient Safety Incident Management System and the new Healthcare Safety Investigation Branch – ooh … two new acronyms

    an NSIMS that replaces the NRLS and an HSIB

  • Enhance the capability and capacity of the NHS to improve safety i.e. support and fund the patient safety collaboratives and the Q initiative
  • Tackle the major underlying barriers to widespread safety improvement

Sign up to Safety will add value to this vision by:

  • Increase understanding locally of what goes wrong through a focus on facilitated safety conversations
  • Enhancing capability and capacity by sharing connections, products, learning and ideas across our membership
  • Tackling the major underlying barriers to widespread safety improvement by steering people away from dealing with one harm at a time to addressing the cross cutting human and system factors and to focus on implementation as much as improvement

Looking forward to further clarity …. watch this space (too many vision/sight references?)


Safe safety conversations 

The next step in the Sign up to Safety team’s exploration into different methods to create ‘safe’ safety conversations happened last week. 

We facilitated a conversation between a group of clinicians and a mixed group of policy makers and patients. 

The subject was investigations. Primarily what does it feel like to be part of an investigation both from the staff and patient perspective. 

We both want the same thing

Was the conclusion at the end of the session. 

Both sides want to be treated as a human being. 

Both want empathy, trust, the truth and forgiveness. To forgive and to receive forgiveness. 

It was a powerful conversation that was so skilfully facilitated by David (Naylor) that at no point did anyone feel unsafe or unable to say really what they wanted to say. 

This time we used a fishbowl (last time we used trios). Same principles:

  • Have a question to explore
  • Give people time to speak 
  • Ensure people really (and I mean really) listen
  • Ask clarifying questions that expand the conversation rather than stifle 
  • Observe what is being said and what isn’t 
  • Make a record of learning themes in real time

I can’t wait for the next experience- we are learning so much.