‘Never Events’ in surgery occur at random and are not related to hospital performance

NHS England defines ‘Never Events’ as “serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented”. In the most comprehensive study of its kind in the NHS to date, every hospital Trust in England was contacted using Freedom of Information requests, and all responded by providing data. Published today in the journal Anaesthesia, the study found that surgical ‘Never Events’ happen approximately once in every 16,500 operations, leading to major harm around once in 250,000 operations. Importantly, the study found that the only major factor influencing the number of ‘Never Events’ at an individual hospital are its size – other measures of safety do not appear to be related to their occurrence. The study authors concluded that “‘Never Events’ are important, but they are rare, apparently random events and are the wrong metric to gauge safety within the operating theatre”.

‘Never Events’ during surgery include events such as performing the wrong operation, leaving objects inside the patient unintentionally, or putting in the wrong size or type of implant. Politicians, commentators and healthcare regulators often cite these events as demonstrating a hospital to be unsafe.

The Anaesthesia study found that 158 English NHS Hospital Trusts reported 742 surgical ‘Never Events’ over a three-year period, encompassing over 3 million operations. Almost 50% of surgical ‘Never Events’ were reported to cause no or minimal harm, and only 7% caused severe harm. There was a small, but insignificant, fall in the number of surgical ‘Never Events’ each year between 2011 and 2013. The rate of surgical ‘Never Events’ seems to be about the same as in the USA.

An average-sized English hospital undertakes around 24,000 operations each year, so based on current rates would be expected to have 1-2 surgical ‘Never Events’ each year. The study found that almost all hospitals had around their expected number of surgical ‘Never Events’ over the three-year period, and that there was no association between the occurrence of ‘Never Events’ and any other measures of hospital safety such as CQC ratings or hospital mortality data (death rates) – only the size of the hospital seemed to matter. Whilst ‘Never Events’ certainly do continue to occur and on rare occasions can be catastrophic, they seem to be relatively unusual. When they do occur, the study authors concluded that this doesn’t imply that the hospital or its operating theatres are particularly unsafe. 

For further information and interview opportunities please contact Stephanie Addington of the Association of Anaesthetists of Great Britain and Ireland on telephone +44 (0)20 7631 8854 and email stephanieaddington@aagbi.org

Article: http://onlinelibrary.wiley.com/doi/10.1111/anae.13261/full

Editorial: http://onlinelibrary.wiley.com/doi/10.1111/anae.13290/full

 

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