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Localised data on 'never events' now available

Localised data on 'never events' now available


NHS England will now publish more detailed data than ever before about “never events” – the serious errors in care that put patients at risk of harm and that should not happen if full preventative procedures are in place.

Quarterly data on the number of never events happening at each hospital trust in England will be published for the first time. Previously, data was published annually at national, aggregated level. 

The data is available on the NHS England website, and will be updated in three months’ time. From April 2014, the data will be updated every month.

Professor Don Berwick, the US expert who earlier this year led a landmark review into patient safety in England, has hailed the publication as an admirable and important step.

Never events include such incidents as wrong-site surgery, items like swabs and other medical equipment being accidentally left inside a patient, and strong drugs like chemotherapy being administered in the wrong way.

The provisional data shows:

 - 102 NHS trusts had at least one never event between April and September this year

 - 8 independent hospitals had at least one never event between April and September this year

 - There were 37 instances of wrong-site surgery in the six months from April to September, and 70 incidents of foreign objects being mistakenly left inside patients.

The data shows that the number of never events recorded is broadly similar to last year. NHS England expects that reporting of these incidents will continue to increase as the NHS becomes a more transparent and learning system, and as the types of incidents that are classed as “never events” continue to increase in line with developments in patient safety practices.

Dr Mike Durkin, national director of patient safety at NHS England, said: “Awareness in the NHS of these issues has never been greater and the quality of our surgical procedures has never been better. It follows that the risk of these things happening has never been smaller.

“This publication is not about ‘naming and shaming’ - it is about telling the public about mistakes, and further ensuring that we talk about and learn from them. That is the way to minimise errors and take every step we can to drive avoidable harm out of the NHS.

“By making this detailed data fully open to public scrutiny, we are fulfilling a key recommendation of the Francis Review, but more importantly we are making a big step towards further reducing these events.”


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