Never events: analysis of HSIB's national investigations — HSSIB Investigation

Summary

3 recommendations 1 observation 15 learning prompts 3 of 3 responded

Safety Recommendations

3 total

R/2021/111 NHS England

It is recommended that NHS England and NHS Improvement revises the Never Events list to remove events, such as those presented in this national learning report, that do not have strong and systemic safety barriers.

NHS England agrees about the varying strength of systemic barriers for Never Events and has commenced a programme of work to review the list to identify where barriers are not robust. They state this review will be an ongoing process.

Response received 16 April 2021

We agree that the systemic barriers for some Never Events are not as strong as others and following on from CQC’s thematic review ‘Opening the Door to Change’ commenced a programme of work to review the list of Never Events to identify which barriers are not as strong as was initially thought. We are grateful to HSIB for their contributions so far to this work. Review of the Never Events Framework and Never Events List will be an ongoing process, as it has been since its first iteration in 2009. Response received on 16 April 2021.

R/2021/112 NHS England

It is recommended that NHS England and NHS Improvement develops and commissions programmes of work to find strong and systemic safety barriers for specific incidents where barriers are felt to be possible but are not currently available.

NHS England states they are not currently aware of significantly stronger possible barriers, so no specific work can be commissioned. They welcome suggestions from HSIB and commit to acting on future developments from innovators or research.

Response received 16 April 2021

We are not aware of significantly stronger barriers that are felt to be possible at this point, so there is no specific work we can commission at present. We would welcome any suggestions from HSIB, based on the evidence that has been collected in preparation for this national learning report, of potential strong and systemic barriers that could be considered further. As I know HSIB appreciates, there are many ways in which NHS England and NHS improvement encourages and supports innovators and innovations, and supports the commissioning of research by the DHSC and NIHR. We will act on any future developments through those routes that have potential to provide strong and systematic barriers. We will also of course continue to support providers to consistently implement established barriers, including the elimination of air flowmeters. Response received on 16 April 2021.

R/2021/113 Centre for Perioperative Care

It is recommended that the Centre for Perioperative Care reviews and revises the National Safety Standards for Invasive Procedures (NatSSIPs) policy to increase standardisation of safety critical steps that are common across all procedures.

The Centre for Perioperative Care has formed a NatSSIPs working group, held an initial meeting, and started reviewing/revising the NatSSIPs policy. They plan to produce a revised version focusing on increased standardisation of safety critical steps, with a drafting timeline in 2021.

Response received 9 March 2021

The Centre for Perioperative Care has already instituted a NatSSIPs working group with wide membership and clear terms of reference. An initial meeting in January 2021 has occurred. We have started on the plan to review and revise the National Safety Standards for Invasive Procedures (NatSSIPs). We will seek views on the practicalities of what might work in any clinical setting where invasive procedures are undertaken. We will review the current NatSSIPs, literature and reports indicating where revision may be required. We will involve our Board members and advisory group members to identify different perspectives. We aim to produce a revised version of NatSSIPs, in particular with increased standardisation of safety critical steps that are common across organisations. We will keep HSIB informed of our progress with the work throughout the project. We will consider different audiences and staff groups and whether specific education is required. We will seek assistance, including from HSIB, with ensuring that our revised NatSSIPs are disseminated widely and used as part of a monitoring framework to assist uptake. Actions: CPOC to institute a NatSSIPs working group. TIMELINE: Dec 2020 - done. First meeting of NatSSIPs working group. TIMELINE: Jan 2021 - done. Further meetings and electronic consultation on key issues identified in the review of current NatSSIPS. TIMELINE: Jan - Sept 2021. Drafting a revision of NatSSIPs. TIMELINE: 2021. Dissemination plan. TIMELINE: 2021. Response received on 9 March 2021.

Safety Observations

1 total

Observation 1 Observation It would be beneficial if significant safety events, such as those presented in this national learning report, continue to be reported and investigated by NHS organisations without apportioning blame or liability, using a recognised systems- based approach such as the Systems Engineering Initiative for Patient Safety (SEIPS) as used in this report. When reading this report HSIB has published this national learning report for a variety of audiences. These include healthcare staff, healthcare academics, patients and the general public. Further information on the Never Event investigations undertaken by HSIB are available via its website: Implantation of wrong prostheses during joint replacement surgery (Healthcare Safety Investigation Branch, 2018a). Administering a wrong site nerve block (Healthcare Safety Investigation Branch, 2018b). Insertion of an incorrect intraocular lens (Healthcare Safety Investigation Branch, 2018c). Piped supply of medical air and oxygen (Healthcare Safety Investigation Branch, 2019a). Detection of retained vaginal swabs and tampons following childbirth (Healthcare Safety Investigation Branch, 2019b). Prescribing and administering insulin from a pen device in hospital (Healthcare Safety Investigation Branch, 2019c). Inadvertent administration of an oral liquid medicine into a vein (Healthcare Safety Investigation Branch, 2019d). Wrong site surgery – wrong patient (Healthcare Safety Investigation Branch, 2020a). Wrong site surgery – wrong tooth extraction (Healthcare Safety Investigation Branch, 2020b). Placement of nasogastric tubes (Healthcare Safety Investigation Branch, 2020c). The following sections of the report are recommended for different audiences: For people new to Never Events who seek to understand the background to Never Events and this report’s key conclusions, HSIB recommends sections 1, 5 and 6. For people working in clinical or patient safety teams who are familiar with Never Events who seek to understand the themes from HSIB’s Never Event investigations and this report’s key conclusions, HSIB recommends sections 4, 5 and 6. For people with an interest in safety science, HSIB recommends reading the whole report, including section 3 and appendix 8.2 where information is provided on the SEIPS approach. This report contains some medical terms related to investigation and Never Events. A glossary relating to concepts and methods is available in section 7. A description of each Never Event is provided in appendix 8.1.

Learning Prompts

15 total

Prompt 1 Learning prompt Implantation of wrong prostheses during joint replacement surgery (Healthcare Safety Investigation Branch, 2018a).

Prompt 2 Learning prompt Administering a wrong site nerve block (Healthcare Safety Investigation Branch, 2018b).

Prompt 3 Learning prompt Insertion of an incorrect intraocular lens (Healthcare Safety Investigation Branch, 2018c).

Prompt 4 Learning prompt Piped supply of medical air and oxygen (Healthcare Safety Investigation Branch, 2019a).

Prompt 5 Learning prompt Detection of retained vaginal swabs and tampons following childbirth (Healthcare Safety Investigation Branch, 2019b).

Prompt 6 Learning prompt Prescribing and administering insulin from a pen device in hospital (Healthcare Safety Investigation Branch, 2019c).

Prompt 7 Learning prompt Inadvertent administration of an oral liquid medicine into a vein (Healthcare Safety Investigation Branch, 2019d).

Prompt 8 Learning prompt Wrong site surgery – wrong patient (Healthcare Safety Investigation Branch, 2020a).

Prompt 9 Learning prompt Placement of nasogastric tubes (Healthcare Safety Investigation Branch, 2020c).

Prompt 10 Learning prompt person(s): the people working in the particular system and the patient

Prompt 11 Learning prompt tasks: undertaken by the persons which may vary in complexity or variety

Prompt 12 Learning prompt tools and technology: used to undertake the tasks which may vary in usability and functionality

Prompt 13 Learning prompt internal environment: the physical space around the persons, for example layout, noise and temperature

Prompt 14 Learning prompt organisation: conditions external to the persons to support the organisation of, for example, resources and activity

Prompt 15 Learning prompt external environment: factors outside of the healthcare institution that might include policy, societal or economic factors.