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

Bowie, P., Baylis, D., Price, J., Bradshaw, P., McNab, D., Ker, J., Carson-Stevens, A. and Ross, A. (2021) Is the “never event” concept a useful safety management strategy in complex primary healthcare systems? International Journal for Quality in Health Care, 33(Suppl1), pp. 25-30. (doi: 10.1093/intqhc/mzaa101) (PMID:33432982)

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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.

Item Type:Articles
Status:Published
Refereed:Yes
Glasgow Author(s) Enlighten ID:McNab, Duncan and Bowie, Dr Paul and Ross, Dr Alastair
Authors: Bowie, P., Baylis, D., Price, J., Bradshaw, P., McNab, D., Ker, J., Carson-Stevens, A., and Ross, A.
College/School:College of Medical Veterinary and Life Sciences > Institute of Health and Wellbeing > Mental Health and Wellbeing
College of Medical Veterinary and Life Sciences > School of Medicine, Dentistry & Nursing > Dental School
Journal Name:International Journal for Quality in Health Care
Publisher:Oxford University Press
ISSN:1353-4505
ISSN (Online):1464-3677
Copyright Holders:Copyright © 2021 The Authors
First Published:First published in International Journal for Quality in Health Care 33(Supplement 1):25-30
Publisher Policy:Reproduced in accordance with the copyright policy of the publisher

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