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What Never Events on PHIN’s website can tell you about hospitals

02/09/2020



When you are receiving treatment, it is important to feel that you are in safe hands. On our website we publish information on a range of patient safety measures including about serious safety incidents. One category of these are known as Never Events. 

Here we explain what Never Events are, why they are measured, and how you can use them when considering which hospital is right for you.


What are Never Events?


Never Events are serious, entirely preventable incidents where a patient has been put at an unnecessary risk. While hospitals can’t prevent all harm to patients, Never Events are incidents which should never happen if the hospital has the right processes in place. These incidents have to be reported, even if there is no apparent harm to the patient.

There are three categories of Never Events: ‘surgical’, ‘medication’ and ‘general’.
 
  • Surgical Never Events include incidents which take place in surgery. For example, if the surgeon operated on the wrong part of the body.
  • Medication Never Events include incidents where patients have been administered the wrong type or wrong dosage of a medication.
  • General Never Events are other incidents which take place in a hospital and include health and safety incidents such as a patient becoming trapped in a hospital bed or falling from a poorly secured window.
     
Never Events should not happen, but when they do, they can have lasting consequences for the patient, their family, and the hospital where they received that care.


Why do hospitals record Never Events?


Hospitals are required to record and investigate all Never Events that take place. The investigations are used to help hospitals understand what went wrong and put in place new processes to prevent similar incidents from happening in the future. 

NHS and private hospitals are required to keep records on Never Events that happen to NHS funded patients and to report them to NHS Improvement, who publish them on their website. Any hospitals treating privately funded patients (including independent hospitals and NHS Private Patient Units) are required to report these Never Events to PHIN.

What Never Events information can I see on PHIN’s website? 


The information you can see on this website shows the Never Events for private patients reported to PHIN. Our website does not currently include Never Events for NHS patients in independent hospitals, which can be found on the NHS Improvement website. 

You can see how many Never Events have occurred at each hospital, as well as the type of incident. Every Never Event is counted separately, regardless if they happened to the same patient, so the number you see is the total number of incidents, not the number of patients affected.  


What can Never Events tell you about a hospital?


Even a single Never Event on a hospital’s profile could lead you to question the care provided, as the expectation is that these incidents should not happen. Hospitals are required to record and investigate all Never Events that take place, therefore should learn from the investigation and put processes in place to stop the incident from happening again.

The first thing you should look for is whether the hospital is monitoring and reporting their Never Events at all. Hospitals that record and report Never Events are likely to have a strong focus on patient safety and learning from past mistakes. If a hospital does not record and report serious safety incidents, they will have ‘insufficient data provided’ on their profile. This may lead you to question whether they adequately monitor safety in their hospitals, and what this might mean for your care. 

You should also look at the different categories of Never Events if they have been reported by a hospital. This can tell you whether the hospital was lacking robust safety procedures in surgery, medication or elsewhere in the hospital. If you are going for any sort of treatment at a hospital, it is still important to ask what actions were taken to stop it happening again and how this could affect you.

The numbers that are on our website cannot tell you the full story of what is going on at each hospital, so this information is best used during discussions with your consultant or hospital.


Your checklist:

 
  1. Check whether your local hospital is reporting their Never Events - If they aren’t, what does this say about safety in the hospital, and what could this mean for your care?
     
  2. Understand your hospital’s Never Events – If your hospital has recorded Never Events, what type of incident was it, what did they do about it and might this be relevant to your care? 
     
  3. Ask questions – Use our information and the published numbers to ask your GP or consultant about the hospital’s safety procedures. You need to be confident that they are the right hospital for you.