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Government tackles medical ‘never events’

Posted in: Medical Negligence 

A number of measures have recently been introduced by the Government in an attempt to make the NHS more transparent and accountable.

In particular, the Government has focused on improving patient safety by reducing the occurrence of so called ‘never events’ throughout Britain’s hospitals.

Never events

Never events are serious patient safety incidents that, by definition, should never happen. These typically include incidents such as surgery being carried out on the wrong part of the body, or surgical equipment being left inside a patient after an operation.

At the end of last year, the Government published details of the number of never events that were reported in the NHS over the previous two years.

The figures reveal that there were an alarming 326 never events reported to Strategic Health Authorities. These included:

  • 161 cases where an object was left inside the patient’s body;
  • 70 occasions when surgery was carried out on the wrong part of the body;
  • 41 cases involving the wrong implant or prosthesis; and
  • 23 incidents of nasogastric tubes being misplaced.

Eradicating never events

NHS Leaders should examine these figures and the guidance that sits alongside them and really focus on driving them out of the NHS,” commented NHS Medical Director Sir Bruce Keogh. He added:

“There are simple ways to prevent them occurring, like the Surgical Safety Checklist, and everyone working in the NHS should ensure that the checklist is being followed,”

Never events are an international problem

The UK is not alone in experiencing a worrying amount of never events in its medical care.

A recent study by researchers at John Hopkins University School of Medicine estimated that 4,044 surgical never events occur in the United States each year.

The researchers made use of the National Practitioner Data Bank, a federal repository of medical malpractice claims, to find cases relating to surgery on the wrong patient, wrong part of the body, or using the wrong procedure. They also looked for retained foreign objects cases.

They found that between 1990 and 2010 there were 9,744 relevant paid malpractice judgments and claims, amounting to $1.3 billion. Just over 6% of the patients involved in the cases had died, 32.9% were permanently injured and 59.2% were injured temporarily.

Increasing patient confidence

In addition to tackling the incidence of never events, the Department of Health has also recently announced new rules to increase transparency in NHS organisations and increase patient confidence.

Under these rules, which are due to come into effect from April 2013, the NHS Commissioning Board will be required to include a contractual duty of openness in all commissioning contracts.

At the moment, there is an expectation that NHS organisations will be open about any mistakes, but there is no contractual duty to hold them to account if this does not happen.

The new rules will mean that NHS organisations, such as hospitals, will be required to tell patients if their safety has been compromised, and ensure that lessons are learned to prevent them from being repeated.


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