This month the National Health Service Executive published the current research in relation to so called “never events”.
These are events that should never occur in hospital but still manage to happen.
Fortunately the number of never events that occur at hospitals has fallen by 10% that however doesn’t alter the fact that 308 still occurred in the last year.
Never events were defined as part of the “duty of candour”. These are events which should never occur, such as operating on the wrong part of the anatomy, leaving foreign objects in the patient post-procedure, and the inappropriate administration of insulin. These are errors that are so fundamental that no member of medical or surgical staff should be involved. Helpfully the published research includes a list of the never events as recorded by the NHS in England.
Tragically the most common type is the wrong site surgery. A proportion of these apparently were the wrong tooth or teeth being removed or the wrong skin lesion excised. For those living in the Colchester area unfortunately Colchester Hospital University NHS Trust was found to be the worst performing with 9 of these never events in the year. This trust also had 420 serious incidents in the past year.
King’s College Hospital in London however was following on the tails of Colchester Hospital having 8 never events.
I have recently been instructed in relation to an anaesthetic awareness case. My client who already had a cannula (by which drugs can be administered) in his arm went for surgery. The cannula in his arm was for morphine to be injected into his tissue at the top of the arm. Anaesthetic medication should be injected intravenously and therefore the cannula would be much further down the arm. However it appears that the anaesthetist didn’t notice the position of the cannula and simply put the anaesthetic medication through the subcutaneous (local tissue) cannula. As a result it was fairly slow to act and although the operation went ahead my client was not anaesthetised. He was however paralysed so he had the dubious honour of being awake through surgery, being able to feel pain but not being able to communicate it. Understandably he is somewhat stressed by this.
This is a never event. What is concerning is that they are still occurring.
A spokesperson for Colchester Hospital Trust apparently reported to the NHS (National Health Executive) that their large number of never events was positive because it showed an organisation which encouraged transparency. This is certainly true. However high reporting is only beneficial if it leads to fairly rapid reduction of incidents occurring at all.
It is not really known at present whether there is going to be a beneficial side effect to hospitals in the increasing reporting of never events. There would clearly be a beneficial side effect to clinicians and patients alike.
It is however concerning that some time after the contractual duty to candour came into being and some time after the NHS hospitals began being penalised financially for their failures such as this, so many never events are still occurring. Moreover trusts which have a high reputation as centres of excellence, trauma centres, leading in their fields such as King’s College Hospital, end up with still a significant number of never events. These are not insubstantial hospitals.
It may be argued that pro rata the number of never events in a hospital treating a larger number of people is considerably less. However the anticipated view is clearly that these centres of excellence should really not be having these problems at all.
We all understand that mistakes happen but these are fundamental mistakes. Many years ago I went to a lecture from a surgeon who confirmed that they had reduced the numbers of errors in surgery by simply having a checklist detailing which limb and where, and double checking it before the patient was operated upon. A simple check list did the job.
The news can therefore be considered either as depressing or good depending on which perspective you come from. Presumably it is viewed very negatively from the families of the 308 people who were subjected to these events. A downward trend is good. Its slow speed of reduction is not.