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Over 300 serious patient safety events reported last year

New data on NHS ‘never events’ reveals vast majority are surgical

Mark Gould

Tuesday, 30 October 2012

New data reveals that there were 161 incidents last year where ‘foreign objects’ were left in patients who had NHS operations.

The figures from the Department of Health data reveal the number of NHS “never events” reported over the last two years. The Department also highlighted fresh action to improve care.

It is the first time that data in 17 of the categories under scrutiny have been reported on making it impossible to compare with previous statistics on NHS adverse events and patient safety scares.

The Department says never events are serious patient safety incidents that, by definition, should never happen. Never events include events such as surgery on the wrong part of the body, or surgical instruments being left in the body after an operation.

The 2011/12 data shows that 326 never events were reported to Strategic Health Authorities, with the most common types of incident being;

  • Retained foreign objects post-operation (161 incidents reported)
  • Surgery on the wrong part of the body (70 incidents)
  • Wrong implant or prosthesis (41 incidents)
  • Misplaced nasogastric tubes (23 incidents)

Following talks with health professionals, royal colleges and the public in 2011, the Government tripled the number of categories that are defined as a never event from eight to 25. To increase transparency and the focus on safety, the NHS has reported on all of these categories in 2011/12.

The vast majority of never events are surgical. The NHS Commissioning Board is setting up a taskforce to look at surgical never events, in order to make sure that these events are eradicated from NHS surgery. Sir Bruce Keogh, NHS Medical Director and Jane Cummings, Chief Nursing Officer, have also written to the NHS today highlighting these figures and setting out what the NHS needs to do to drive the numbers down across all areas.

Health Secretary Jeremy Hunt said: “We know that transparency saves lives and improves care. The NHS treats a million people every 36 hours, and we know that the vast majority of these patients have excellent care. But the NHS needs to do more to really tackle these events. The NHS Commissioning Board is now setting up a taskforce to eradicate these never events from NHS surgery.”

NHS Medical Director Sir Bruce Keogh said; “NHS Leaders should examine these figures and the guidance that sits alongside them and really focus on driving them out of the NHS.

“There are simple ways to prevent them occurring, like the Surgical Safety Checklist, and everyone working in the NHS should ensure that the checklist is being followed.”

Some never events were also reported to the National Reporting and Learning System (NRLS), and these amounted to 163 in 2011/12. This is a separate reporting system and the majority of these reports correspond to incidents also reported to the SHAs, so the totals cannot be added together. Historically the NHS has reported these incidents in different ways. This can lead to confusion and this is why the NHS Commissioning Board is also developing a single incident reporting and management system as part of its work.

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