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Never Events (NE)
Context:
The concept of never events refers to serious and largely preventable incidents that should never occur in healthcare settings if proper safety protocols are followed.
- There is concern that accountability is disproportionately placed on frontline healthcare workers, overlooking systemic failures like organisational inefficiencies, poor infrastructure, and communication gaps.
Understanding Never Events:
- The term was introduced in 2002 by the National Quality Forum (NQF) in the United States, the term has since been adopted in the Western world, including countries like the USA, UK, and Canada
- Never events are incidents that result in severe patient consequences, such as operating on the wrong body part, insulin overdose, or mismatched blood transfusion.
- These events can lead to disability, death, or great discomfort for the patient.
- The concept of never events overlaps with terms like “sentinel events” and “serious reportable events.”
- The list of never events differs across organisations. For example, the UK’s NHS (2021) lists 16 events, while the US recognises 29 events.
Steps After a Never Event:
- Apology: The healthcare provider must offer a sincere apology to the patient, acknowledging the error.
- Formal Reporting: The event must be transparently reported to appropriate regulatory bodies and authorities.
- Root Cause Analysis: A thorough analysis is essential to identify the underlying factors that led to the incident. This helps in understanding the specific breakdowns in processes, communication, or systems that allowed the event to happen.
- Waiving Costs: Any additional costs incurred due to the incident should be waived, as a gesture of accountability and fairness.
Challenges in Prevention:
- While achieving absolute prevention is often seen as the ultimate goal, no consensus remains on whether it is practically possible.
- Studies reveal that never events persist at a rate of 1 to 2 per 100 incidents, with overall patient safety incidents occurring in 2 to 3 out of every 100 consultations.
- The complexity of healthcare systems and the interplay of various factors make it challenging to completely eliminate these events.
- The complexity of healthcare systems, involving numerous stakeholders and interactions between social, technical, human, organizational, economic, and regulatory components, makes the complete prevention of never events a challenging goal.
The Indian Context
- The term “never events” is not explicitly used in India. Instead, incidents are categorised under medical negligence, which applies to allegations of professional misconduct.
- Medical Negligence: Defined by the Bolam test, it occurs when a healthcare provider fails to meet the standard of care, leading to harm.
- Medical Errors: Unintended mistakes arising from misjudgments or incorrect treatment, not deliberate deviation from care standards.
- Iatrogenic Events: Harm caused by medical interventions, some of which are unavoidable (e.g., hair loss from chemotherapy), while others (e.g., retained surgical items) indicate negligence.
- Medical Maloccurrences: Outcomes that cannot be prevented even with proper care (e.g., rib fractures during CPR).
- Medical Complications: Expected risks inherent in medical procedures, which do not imply negligence, and are different from iatrogenic causes.
