A never event is the “kind of mistake (medical error) that should never happen” in the field of medical treatment. These are serious, largely preventable events but have terrible consequences for the patient.
Doctors and nurses are encouraged to learn from mistakes. Any hospital that reports a Never Event is expected to conduct its own investigation so it can learn and take action on the underlying causes. They are encouraged to apologised. Yet the event is often so serious as to leave the patient with life changing injury.
The figures are alarmingly consistent year on year:
There are currently 25 specified never events, of which only three have been defined as ‘surgical’ never events.
A surgical intervention performed on the wrong site (for example wrong knee, wrong eye, wrong patient, wrong limb, or wrong organ). The incident is detected at any time after the start of the operation and the patient requires further surgery, on the correct site, and/or may have complications following the wrong surgery.
This includes biopsy, radiological procedures and drain insertion, where the intervention is considered surgical.
Surgical placement of the wrong implant or prosthesis where the implant/prosthesis placed in the patient is other than that specified in the operating plan either prior to or during the procedure. The incident is detected at any time after the implant/prosthesis is placed in the patient and the patient requires further surgery to replace the incorrect implant/prosthesis and/or suffers complications following the surgery.
Retention of a foreign object in a patient after a surgical/ invasive procedure. ‘Surgical/ invasive procedure’ includes interventional radiology, cardiology and interventions related to vaginal birth. ‘Foreign object’ includes any items that should be subject to a formal counting/ checking process at the commencement of the procedure and a counting/ checking process before the procedure is completed (such as swabs, needles, instruments and guidewires) except where:
The distress these errors cause to patients and their families is significant. Patients don’t go into hospital expecting errors to occur and rightly anticipate that their entire experience will be safe and error-free. With the use of checklists in the theatre and provision of patient notes once would hope that such serious injury from Never Events could not occur but they do. Many patients die as a result of these events.
It is so very important that the patient (or family) receive a sincere apology, and an explanation of what went wrong and how it will be put right. This is every doctor’s ethical duty, and now also a contractual obligation under the duty of candour.
Preventable things can and do go wrong, sometimes with severe consequences for the patient.
If you think you may have a claim related to Serious Injury (Never Event) then call us in confidence to discuss your issue. We are happy to talk through what has happened and advise you on a potential claim. Call us for FREE on 0800 470 2009 or email Dr Victoria Handley at firstname.lastname@example.org