Never events are serious incidents defined as ‘wholly preventable, where guidance or safety recommendations that provide strong systematic protective barriers are available at a national level and should have been implemented by healthcare providers.’ Never events have the potential to cause serious patient harm or death, however serious harm or death is not required to have happened for the incident to have been classified as a never event.
Any never event reported is escalated via our serious incident process and is subject to a detailed investigation with actions on learning. The Trust monitors never events as can be seen in the graph below.
Changes have been implemented to drive down never events across East Kent Hospitals. Following thorough investigations we have made improvements to procedures in theatres and wards. We have standardised practices and introduced new systems and processes, many of which being supported by new technology. Safety in healthcare is not only the result of having good standards but it is also dependent on the efficiency of individuals and teams who deliver care and treatment. So alongside improving systems, staff have also focused on ‘human factors’ and introduced safety techniques such as team briefings, checklists and ways to communicate and escalate concerns.
NHS England published the Never Events List 2015/16.