Defining healthcare never events to effect system change: A protocol for systematic review

Abstract

Introduction A never event is the most egregious of patient safety incidents. It refers to events that should theoretically never happen, such amputating the wrong limb. The term “never event” is used around the world by a variety of medical and patient safety organizations and is synonymous with sentinel events and serious reportable events. Unfortunately, there is little consensus about which events, in particular, are never events. These differing lists hinder potential collaboration or large-scale analyses. A recent systematic review by Hegarty et al. (2020) identified the need for a standardized definition for serious reportable events. The objective of our systematic review is to build on this by identifying which events are consistently or frequently identified as never events in order to isolate those which are core never events. Materials and methods A systematic review will be conducted using Medline, Medline in Process, Scopus, PsychINFO, Embase via OVID, and CINAHL via EBSCO databases, as well as grey literature. We will include articles of any study design that discuss never events or one of its synonymous terms in the context of medical care. Four independent reviewers will conduct the title and abstract as well as the full-text screening, and 2 reviewers will abstract data. Data will be analyzed using narrative synthesis. Results will be categorized by year and geographic location, and by other factors determined during full-text screening. Discussion and conclusion The lack of consensus regarding never events hinders progress in reducing their occurrence. Differing data sources makes comparison challenging, and limits the ability for patient safety groups to work collaboratively and share learnings with others. Identifying a core set of never events will serve as a first step to focus our efforts to reduce these harmful incidents.

Identifying a list of healthcare ‘never events’ to effect system change: a systematic review and narrative synthesis

“…It also impedes the ability of organisations to collaborate and learn from each other to reduce the occurrence of these events. 1 This narrative synthesis systematic review aims to improve standardisation by answering two questions posed in our protocol 1 : Which patient safety events do organisations and researchers most frequently classify as NEs? Which ones are most commonly described as entirely preventable?…”

“…SPIDER was chosen as it does not require a study intervention or outcome and is more appropriate for reviews that use qualitative synthesis. 14 Full details on our methods and eligibility criteria have been published previously 1 and are outlined in table 1. We included peer-reviewed and grey literature reports that discussed patient safety events that should never happen.…”

“…Never events (NEs) are a subset of patient safety incidents that are preventable and so serious that they should never happen 1–3. Examples include operating on the wrong patient or incompatible blood transfusion.…”

“…The lack of standardisation on what constitutes an NE can hinder our efforts to identify, report and manage them. It also impedes the ability of organisations to collaborate and learn from each other to reduce the occurrence of these events 1…”

The Complicated Decisions Required to Eliminate Never Events

“…The definition, although once very focused on glaring occurrences such as wrong side surgery, has expanded to cover both anticipated and unanticipated complications. 1,2 Key components in eliminating complications include discovering underlying causes and enacting applicable changes.…”