The focus on patient safety in healthcare is at the forefront of ensuring the provision of high quality healthcare.1 Diane Baylis, clinical risk educator at Medical Protection, tells us more about the concept of ‘never events’ and how they can improve patient safety.
The terms ‘quality’ and ‘safety’ are increasingly being used synonymously, and attaining a high level of safety is an essential step in improving the quality of care. This is becoming more challenging in general practice, particularly when confronted with unprecedented financial challenges and rising service demand.2
There is growing international evidence that by adopting similar strategies to other high risk industries, healthcare organisations can reduce variation and improve patient safety.3 Similar to secondary care settings internationally, there is growing interest in the concept of ‘never events’ in UK general practice.
What is a ‘never event’ list?
A ‘never event’ list is a definitive list of serious medical errors that are deemed to be preventable and should never occur.4
Never event lists are used worldwide in healthcare to increase understanding and knowledge of potentially serious patient safety incidents, and to apply relevant precautionary measures to improve patient safety.5
The ultimate aim of a ‘never event’ list is to improve patient safety by preventing the incident from happening again.
Research approach
By looking at serious adverse events that occur in general practice, a list of ‘never events’ could be developed specifically for general practice. A review of previous research highlighted the importance that incident reporting plays with regards to patient safety.6
It also supported the claim that serious adverse events in general practice can be classified as ‘never events’, as they pose an equal risk to patient safety.7 Most of the research into improving patient safety in healthcare has previously focused predominantly on hospital care6 and research into adverse events in general practice has received significantly less priority.8
Medical Protection invited GPs from the north west of England to take part in an online survey in 2016 to give their opinion on whether a specific incident should be included on the final ‘never event’ list for general practice. The final list was based on the 103 responses.
Findings
From the 54 questions regarding serious adverse events, a list of 21 potential ‘never events’ for general practice was developed.
The justification for a type of serious adverse incident being included on the ‘never event’ list is that there are systems and barriers to prevent it from happening and that sufficient guidance is in place to ensure it should never happen. However, if such significant patient safety incidents are to be taken seriously, the primary care workforce would need to be upskilled in ‘systems thinking’ to properly examine the complex system interactions that contribute to such events.
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Key ‘never events’
· ‘The failure to send a referral of a patient, prompted by a clinical suspicion of cancer’ received the highest proportion of agreement, indicating a very high awareness among GPs that this is a serious risk and should be classed as a never event.
· Incidents relating to prescribing and medication issues were prevalent on the list, indicating a high awareness of the known risks relating to prescribing in general practice.
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‘Never events’ are vital indicators that systems and barriers to known serious errors had failed.
Comments provided by the GPs who took part in the study served to highlight some key concerns. Common themes that emerged from the comments provided in the survey were:
- Concerns that the high workload and pressurised environment in general practice impacts on the likelihood of making a mistake by omitting to undertake some tasks.
- Practices deal with many test results on a daily basis and the degree of urgent response is variable and the impact on patient outcomes can be serious. The failure to follow up test results is recognised as a crucial patient safety issue.9
- Adverse events involving communication are frequent, and communication errors, particularly through primary/secondary care interface, often occur due to incorrect or illegible hospital discharge letters.
Recommendations
The study provided a ‘snapshot’ of opinions and served to highlight the scale and type of serious adverse events in general practice.
Practice teams can use this never events list as a guide for identifying potential serious adverse events and put systems and barriers in place to prevent them from occurring.
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Acts of omission
1. A planned referral of a patient, prompted by a clinical suspicion of cancer, is not sent.
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Investigations
2. An abnormal test result is received by a practice but not considered for action, or the considered action is not performed.
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Prescribing medication, when known, absolute contraindications exist
3. Prescribing teratogenic drugs to a patient known to be pregnant.
4. Prescribing combined oral contraceptive after previous confirmed DVT/PE.
5. Prescribing oestrogen-only HRT for women with intact uterus.
6. Prescribing a drug to a patient that has correctly been recorded in the practice system as having previously caused them a severe adverse reaction.
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Medication (prescribing, dispensing, administration, monitoring)
7. Prescribing 'high risk' medication without ensuring adequate monitoring took place and results were satisfactory.
8. Giving the right drug via the wrong route or at the wrong site.
9. Prescribing immunosuppressives daily rather than weekly (unless initiated by a specialist for a specific clinical condition, eg leukaemia).
10. Prescribing aspirin for a patient under 12 years old (unless recommended by a specialist for a specific condition, eg Kawasaki's disease).
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Medicolegal and ethical incidents
11. Physical assault of patients or healthcare workers.
12. Ignoring a patient's living will.
13. A practice team member working while intoxicated.
14. Losing controlled drugs.
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Clinical management
15. Not referring a patient presenting with and treated for anaphylaxis to secondary care for observation.
16. Not referring a child suspected to have non accidental injuries urgently.
17. Performing a cervical smear without visualising the cervical os.
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Practice systems
18. A practice does not have an up-to-date and secure backup of their data.
19. Medical waste and hazardous substances discarded in an inappropriate manner.
20. Emergency medical equipment, eg defibrillator, is not in working order, maintained, available or checked regularly.
21. A needlestick injury due to a failure to dispose of 'sharps' in compliance with national guidance and regulations.
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References
1 Edozien L, The RADICAL framework for implementing and monitoring healthcare risk management. Clinical Governance: An International Journal 2013;18:165-175. doi:10.1108/14777271311317945
2 Baird B, Charles A, Honeyman M, Maguire D and Das P, (2016). Understanding pressures in general practice. London: The King's Fund
3 Dixon J, Spencelayh E, Howells A, Mandel A, Gille F, Indicators of quality of care in general practices in England. London: The Health Foundation; 2015
4 NHS England (2015) Serious Incident Framework. NHS England, Patient Safety Domain. NHS England. London.
5 Emslie S, Knox, K and Pickstone M (2002) Improving patient safety: Insights from American, Australian and British healthcare. Department of Health: London.
6 Vincent C and Esmail A (2015). Researching patient safety in primary care: Now and in the future. European Journal of General Practice 21(1), 1-2.
7 Stahel PF, Sabe l AL, Victoroff MS, Varnell J, Lembitz A, Boyle DJ, Clarke TJ, Smith WR and Mehler PS (2010). Wrong-site and Wrong-patient procedures in the universal protocol era: analysis of a prospective database of physician self-reported occurrences. Archives of Surgery 145(10), 978–984.
8 National Patient Safety Agency. (2009). Seven steps to patient safety. National Patient Safety Agency.
9 Kwan J and Cram P (2015). Do not assume that no news is good news: Test result management and communication in primary care. British Medical Journal of Quality and Safety 24(11), 664-666.