Saturday, 5 March 2011

Never Events

The lovely Andrew
Never events should never happen - but they will, for to err is human.  Never events happen in health care settings and sometimes in a patients home.  Never events cover wrong site surgery to an overdose of insulin.

A previous list of eight never events has recently been increased  to twenty-five and details can be found here.  There are one or two detailed there that I have great concerns with -  with regard to inappropriate use and one of them reminds me very much of Dr Jane Barton.  We have a guidance plastered on the clinic wall at work re the opioid naive patient and as said, whenever I read it - I think of her; but that is another matter.

I do not think that any surgeon, nurse or technician deliberately leaves instruments. etc in operation sites, nor do I think that a doctor or nurse deliberately overdoses a patient - forget nutters like Beverly Allitt for this is not about them.  Errors should never occur - but they will.
Now the list of never events is greater - it stands to reason that the number of actual events per year will increase.

I have given the wrong medicine to residents twice - perhaps more than this and I am unaware of it?  It wasn't a deliberate action, but caused by a moments distraction.

Health Secretary (the lovely) Andrew Lansley has declared that understaffing is not an excuse for 'never events'.  What's that you say "Understaffing?"  So he finally admits that wards are understaffed!  This issue of course does not limit itself to nursing and includes doctors and midwifes.  The more doctors and nurses are made redundant or not replaced (despite election promises to protect front-line staff) - the more never events will occur.

However, this post is based on an interview with dear Andrew in the Nursing Times (which occasionally rises above the banal) in which he declared he would not tolerate excuses from nurses who blamed life-threatening mistakes on understaffing and being over-stretched.

A wag left this brilliant comment:  "Presumably if staffing levels have nothing to do with safety, one nurse could run the entire NHS?????"

Beware doctors and nurses - the shit won't hit the fan - it will hit you!

Anna :o]

6 comments:

Eliza said...

Great post, so true. All of us on the front line will needs to watch our backs! It will always be us that takes the wrap, management will wriggle out of any tight corner they get themselves into!

Friko said...

I may have witnessed what you call a 'never' event, probably caused by understaffing and a very tired, short-tempered, irritable nurse during the night session at a largish hospital in Shropshire.

The young patient, a beautiful French girl over here for just a two week holiday survived by the skin of her teeth and a mad scramble by intensive care staff in the morning after this nurse finished her shift.
Until then nobody took a blind bit of notice.

I have every reason to be grateful for the NHS but I doubt that the young woman went home singing the NHS's praises.

Thank you for following me at Friko's Poetry and Pictures. That blog is for my personal pleasure and pays little attention to other bloggers. Friko's World is a much friendlier place and I'll pop over from there.

witchdoctor said...

I seem to recollect that the concept of "Never Events" originated across the Atlantic. Money is involved. One advantage of defining never events is that the insurance companies would not pay out for the medical consequences of these.

http://www.kevinmd.com/blog/2008/04/whitecoat-never-say-never.html

"More importantly, insurers are concerned with profits over prevention. They can try to improve their public image by touting “patient safety”, but actions speak louder than words. The reason that insurers aren’t paying for these events is because they can then charge patients more and more for insurance premiums, while using the guise of “never events” to pay less and less for the medical care that their patients receive.

By blaming the hospitals for events that some government-sponsored coalition says should “never” happen, they can increase their profits and vilify the “dangerous” health care providers. A win-win situation for the insurers and a lose-lose situation for the medical providers. It’s all about the Benjamins. WellPoint and Aetna didn’t crack the Fortune 500 by deciding to pay more for medical care."

HyperCRYPTICal said...

Thanks for your comments folks!

Eliza: We will all have to watch our backs for as sure as eggs is eggs, poor staffing resources will not be considered by management as we arn't understaffed - according to them!

Friko: Errors will always occur unfortunately and are never deliberate - in any setting, not necessarily healthcare. As NHS frontline staff become increasingly overstretched I am certain that errors will increase. Sad, but true.

Witchdoctor: Research would suggest that 'Never Events' did originate across the pond and I am certain that the cost of never events is the prime aim of the document.

2.3. Cost Recovery.

'Respondents have concerns with the principle of cost recovery. ...had the potential for discouraging reporting of incidents, perpetuating the blame culture and reducing openness....'

I can relate to the above re drug errors and have questioned myself as to whether I would openly report (my) drug errors - as I have done in the past - now that all drug errors should be reported to the NMC. I like to think I would - but would I if there was no potential for harm?

It is all about cost as in the 'Expanding the list of never events (PDF, 207) ....NSSA's 2009-10 annnual report indicated there were 111 never events in 2009-10..... over 2.1m was paid in relation to clinical negligence claims for wrong site surgery...'

I am sure that there is no clearly defined reason for never events - but poor staffing resources surely will increase the potential for error. In view of this, it is probable that 'savings' in staff reduction will be overtaken by costs incurred for 'negligence'

What is the world coming to?

Anna :o]

ned ludd carer said...

Never events happen - people even die (all of us eventually). Meanwhile there's a life to be lived, and as a carer for someone with severe disabilities, I see daily my sons life being pulled further and further in because nurses are (understandably) increasingly afraid that if anything happens they will be blamed.
I don't have an answer other than to rail against the litigation and blame culture we operate in but I'd welcome others railing as well. This forced back covering is getting as bad as the old discredited Health & Safety assessments eliminating any activity for the disabled out of bounds.
Rant over (temporarily).

HyperCRYPTICal said...

Apologies for the delay in responding Ned as I have just come across your comment.

Rant all you like my friend for what you say is indeed true. In todays world risk assessments abound which become paper vices that limit the potential of every action.

Life is a risk and risks have to be taken. Errors (including never events) occur and always will.

If only we could change the rise of the blame culture - but I fear that we cannot as we all are watching our backs!

Anna :o]