BOA Response to Never Events
As reported by the Telegraph, NHS Improvement have published provisional figures of the occurrence of Never Events between April 2016 and March 2017. During this period, there were 424 reported Never Events, including 178 operations on the wrong body part or patient, 109 foreign objects left inside patients after the operation, and 49 wrong implants or prostheses, of which 24 were incorrect hip or knee implants.
The British Orthopaedic Association (BOA) takes the issue of Never Events very seriously and, in support of this we have a representative (currently Mr Richard Parkinson) on the CORESS Advisory Committee (CORESS is an independent charity, which aims to promote safety in surgical practice in the NHS and the private sector.1) The BOA supports and advises root-cause analysis of these events and encourages the use of the reporting structure of the NHS to ensure there is full and open discussion of these events as a multidisciplinary team review.
The BOA welcomes all efforts to improve patient safety and to encourage a culture of safety in our hospitals and operating rooms. We believe that an improving safety culture is reflected in increased reporting of incidents, and that this leads to learning and ultimately safer services.
We encourage all parts of the health system to take responsibility for delivering the highest quality care and learning from incidents when they occur. In order to achieve this there needs to be embraced a ’just culture’ environment, ensuring that those instigating reports are not regarded by the institution in which they work as the cause of the problem.
Despite the Telegraph’s claim that Never Events are at “near record levels”, it should be noted that the number is broadly consistent with the previous year (when 442 cases were reported), according to the provisional data. There needs to be a further careful analysis of these events which should be discussed in an open culture to make sure the lessons are learnt.
The desire of news media to go for the headline needs to be kept in mind as regards the potential exposure of any health care professionals that have been involved in the Never Event; such media attention can have a damaging impact on an open just culture, and we urge media outlets to avoid covering these issues in such a manner. There can even be a risk that people will not report a Never Event due to concerns about media exposure, although we highlight that reporting is a national requirement and all never events should be reported.
If you have any comments on this issue, please contact [email protected].