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.
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