The term ‘never event’ conjures up only one meaning: it should NEVER happen and you would be forgiven for believing the same. However, recent statistics highlighted in The Telegraph have shown that the NHS mistakes that “Never” happen have nearly doubled over the past year.
Examples of ‘never events’ include operating on the wrong side of the body, leaving swabs or instruments behind during surgery, incorrect administration of insulin (which can kill) and misplaced feeding tubes, which mean that a patient can drown on the food/fluid which is administered down the tube.
The astonishing statistics show that ‘never events’ rose from 163 to 299 in just twelve months. In addition the Department of Health has said there were further reports made to other health authorities so the figures in that year were actually higher than what was officially reported.
A previous BBC investigation into these events showed that over a four year period 762 patients suffered such errors. These included medical instruments left in the body after surgery; one woman had a pair of forceps left in her following a routine gall bladder operation. When doctors tried to diagnose the source of her continuing pain, a routine MRI scan caused her untold agony as the strong magnets tried to pull the metal forceps from her body.
Consequently, over the coming months NHS Trusts will be ordered to publish quarterly lists detailing the amount and type of all errors, so that hospital performance can be compared and monitored.
It certainly is worrying that in the 21st century surgeons are still leaving behind their instruments, especially during routine surgery, when a simple count of the instruments should show the error immediately before the patient is closed. We cannot place blame entirely on the surgeon though, as part of the scrub nurse’s job is also to ensure that what goes in, comes out.
The catalogue of errors reported can and should be avoided and there is no excuse for them ever to have occurred in the first place, which is why they are categorised as ‘never events’. They are clearly still happening!