Never events in general practice

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.

‘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.

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.