Is the ‘never event’ concept a useful safety management strategy in complex primary healthcare systems?

Abstract

Why is the area important? A sub-group of rare but serious patient safety incidents, known as ‘never events,’ is judged to be ‘avoidable.’ There is growing interest in this concept in international care settings, including UK primary care. However, issues have been raised regarding the well-intentioned coupling of ‘preventable harm’ with zero tolerance ‘never events,’ especially around the lack of evidence for such harm ever being totally preventable. What is already known and gaps in knowledge? We consider whether the ideal of reducing preventable harm to ‘never’ is better for patient safety than, for example, the goal of managing risk materializing into harm to ‘as low as reasonably practicable,’ which is well-established in other complex socio-technical systems and is demonstrably achievable. We reflect on the ‘never event’ concept in the primary care context specifically, although the issues and the polarized opinion highlighted are widely applicable. Recent developments to validate primary care ‘never event’ lists are summarized and alternative safety management strategies considered, e.g. Safety-I and Safety-II. Future areas for advancing research and practice Despite their rarity, if there is to be a policy focus on ‘never events,’ then specialist training for key workforce members is necessary to enable examination of the complex system interactions and design issues, which contribute to such events. The ‘never event’ term is well intentioned but largely aspirational—however, it is important to question prevailing assumptions about how patient safety can be understood and improved by offering alternative ways of thinking about related complexities.

Variability in Serious Safety Event Classification among Children’s Hospitals: A Measure for Comparison?

“…Although hospitals utilizing the "Ohio modification" SSE 1-4 taxonomy were seeking to determine temporary harm more clearly and more consistently, it is likely that interpretive variation still exists among hospitals using any scoring system, as determining the level of harm requires discussion and judgment. 1,2,[10][11][12] HPI's SEC attempts to mitigate this issue by providing examples of harm for each severity level and case examples for hospitals to utilize when applying the harm severity scoring. However, given the wide variety of safety events that occur in healthcare, teams applying the SSE classification to adverse events often need to make this determination without additional guidance.…”

“…Developing standards and accurate measures for patient safety improvement have been an evolving process. [1][2][3][4][5][6] While there are metrics for specific types of hospital-acquired harms (eg, hospital-acquired infections, adverse drug events, pressure injuries) [7][8][9] and others proposed, 2,4,10 there is not an agreed-upon single standard, accurate, validated measure to assess overall patient safety improvement. 1,3,[4][5][6][11][12][13] In this context, the evolution and spread of many types of public reporting of quality and safety metrics has resulted in a limited benefit to people seeking either to choose among care providers or to evaluate improvements in safety in individual hospitals, health systems, regions or countries.…”