Description

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Context

While never events might be reduced, complete prevention is more aspirational than practical. Adopting the ALARP (As Low As Reasonably Practicable) principle offers a pragmatic framework for addressing and minimising these incidents.

Details

The concept of Never Events was introduced in 2002 by the National Quality Forum in the United States. These events are broadly defined as serious, largely preventable incidents that should never occur in healthcare settings if proper safety protocols are followed.

Over time, this framework has been adopted in countries like the U.S., U.K. and Canada to emphasize the critical importance of patient safety and strict adherence to safety protocols.

Characteristics

Never Events: Serious and preventable incidents such as wrong-site surgeries or mismatched blood transfusions resulting in severe harm, disability or death.

Overlap with Related Terms: Often used interchangeably with "sentinel events" or "serious reportable events," all emphasizing preventable harm in healthcare.

Common Examples:

Surgery on the wrong body part.

Administration of lethal medication doses.

Retained surgical instruments post-procedure.

Organizational Approaches to Never Events

Several organizations aim to enhance patient safety but differ in how they define and address never events:

National Health Service (NHS) (UK): Maintains a list of 16 never events as of 2021.

United States: Recognizes 29 never events as outlined by agencies like Leapfrog Group.

Cigna and Leapfrog Group: Focus on financial accountability, transparency and systemic learning through root cause analysis.

Steps to Address Never Events

Providers must issue a sincere apology to the patient.

Transparent documentation of the incident is essential.

Investigate systemic and operational factors contributing to the event.

Any costs arising directly from the incident should be borne by the institution.

Debate on Full Preventability

Challenges in Achieving Zero Never Events:

Despite advanced safety protocols, studies reveal the occurrence of 1 to 2 never events per 100 incidents.

Socio-technical complexities including organizational inefficiencies and cultural factors contribute significantly.

The ALARP (As Low As Reasonably Practicable) principle provides a pragmatic framework to minimize risks rather than achieve absolute elimination.

Systemic vs. Individual Accountability:

Overemphasis on frontline healthcare workers often ignores broader systemic failures like inadequate infrastructure or communication gaps.

Addressing systemic inefficiencies is essential to reducing the frequency of never events.

Variations in Lists Across Systems:

Different healthcare systems define never events uniquely influenced by socio-technical, economic and regulatory components.

Example:

NHS (UK): Focuses on 16 critical events.

United States: Includes a broader scope of 29 events.

India: Operates within a medico-legal framework emphasizing medical negligence over defined never events.

The Indian Context

In India, the term Never Events has not been explicitly adopted. Instead healthcare issues are addressed under medical negligence categorized broadly as:

Acts of Commission: Errors like administering incorrect medication.

Acts of Omission: Neglect such as failing to identify retained surgical material.

Distinctions in Medical Errors

Category	Definition	Examples
Medical Errors	Unintended mistakes without deliberate deviation from care standards.	Missed diagnosis, incorrect treatment.
Iatrogenic Events	Harm directly caused by medical interventions, acceptable or negligent.	Hair loss in chemotherapy, retained instruments.
Medical Maloccurrences	Unpreventable outcomes even with optimal care.	Rib fractures during CPR, rare recanalization of fallopian tubes.
Medical Complications	Expected risks of procedures that do not imply negligence.	Post-operative infections despite precautions.

Sources:

Hindu

PRACTICE QUESTION

Q.With reference to Never Events in healthcare consider the following statements:

Never events are internationally standardized across all healthcare systems to ensure global consistency in reporting and prevention.
They are based on a dual premise of preventability and the presence of existing national or local guidelines to avoid such incidents.
The classification of an incident as a never event can vary between countries based on differing healthcare practices and priorities.

Which of the statements given above is/are correct?

(a) 1 and 2 only

(b) 2 and 3 only

(d) 1, 2 and 3

Answer: (b)

Explanation:

Statement 1 is incorrect. Never events are not internationally standardized. Different countries have distinct lists of never events based on their healthcare systems, safety priorities and guidelines.

Statement 2 is correct. Never events are defined by two critical criteria: (1) they are preventable through adherence to guidelines or protocols and (2) robust systems and checks exist that if implemented correctly can avoid such occurrences.

Statement 3 is correct. The classification of incidents as never events can differ between countries. For instance while some countries may include severe medication errors others may prioritize surgical errors or healthcare-associated infections depending on local healthcare challenges.