NHS
never events list to be extended to 25 An extended list of
events that should never happen during care in the NHS has been
unveiled today along with a powerful financial disincentive, as
the Government affirms that substandard care will not be tolerated
in the NHS.
After engaging publicly with health partners like the NHS, health
professionals, the Royal Colleges and the public, the current list
of eight never events is to be extended to 25, and will now
include events like:
severe harm/death due to transfusing the wrong type of
blood;severe scalding; andsevere harm/death due to misidentifying
patients by failing to use standard wristband identification
processes
“Never events” can cut a life unnecessarily short or result in
serious impairment. It is important that the NHS tackles this
issue head-on and continuously strives to provide the safe and
high quality care patients expect. The NHS will still have a
statutory requirement to report all serious patient safety
incidents to the National Reporting and Learning System and to the
CQC. Reporting of patient safety incidences plays a fundamental
role in ensuring that the NHS learns the lessons from its
mistakes, and makes sure they are never repeated.
Health Secretary, Andrew Lansley said:
"Our ambition is to modernise the NHS so that people
have the highest quality healthcare, and live healthier,
independent lives.
“Improving patient safety is central to this. We have identified
25 preventable incidents – “never events” – which should never
happen in a high-quality healthcare service and for which payment
can be withheld across the NHS.
“Never events” will be enshrined in the NHS Standard Contract,
meaning that payment from GPs or other commissioners will be
withheld where care falls short of the acceptable standard. The
measures will help to protect patients and give commissioners the
power to take action if unacceptable mistakes do happen.”
NHS Medical Director, Professor Sir Bruce Keogh
said:
"The extended list includes avoidable incidents with
serious adverse consequences for patients. No one wants these to
happen, therefore we should not have to pay hospitals when these
events occur. This will send a strong signal to leaders of the
organisation to learn from their mistakes so they don't
happen again."
There were 111 “never events” last year and more generally,
medical errors of all kinds have been estimated to cost the NHS
around £2bn a year. It is clear that safer care is cheaper care
and that resources can and should be used to develop better health
outcomes from the start of treatment rather than in putting things
right when they have avoidably gone wrong.
Where "never events" do occur in the NHS,
commissioners will now have the power to withhold payment for this
extended list of events to NHS providers. “Never events” are so
serious that the Government is defining the list of events on a
national basis. However, it is right that local commissioners
decide to what extent they will recover the costs of care
associated with a “never event”. Commissioners will be able to cap
the amount recovered if they choose to.
Notes to Editors
1. For further information, contact the Department of Health
press office on 020 7210 5221
2. A “Never event” is a very serious, largely preventable patient
safety incidents that should not occur if the relevant
preventative measures have been put in place.
3. It is estimated that never events themselves cost the taxpayer
at least £35,000 each a year (or £3.9 million based on 111 events
experienced during the year between Jul 2009 and Jun 2010).
4. Cost recovery relates to the cost of the care episode in which
the “never event” occurred, and if appropriate the cost of the
care needed to treat the consequences of the “never event”.
Commissioners have the discretion to waive cost recovery if they
agree with the provider that this is appropriate.
5. To ensure cost recovery is proportionate, commissioners can
consider using caps on the maximum amount of money they recover.
For certain “never events”, it may not be possible to distinguish
the costs of the relevant procedure from the extremely large costs
of a significant period of care, such as the cost of a long period
of inpatient care. This means the commissioner could impose a very
large financial penalty on the provider. Where there is the
potential for this to be an issue, commissioners and providers
should discuss what principles to apply in advance, while agreeing
contracts. We have suggested they agree to cap cost recovery to
the equivalent of a month’s inpatient stay, or at a monetary level
of, for example, £10,000.
6. The full list of the 25 “Never Events”-
1. Wrong site surgery (existing)
2. Wrong
implant/prosthesis (new)
3. Retained foreign object
post-operation (existing)
4. Wrongly prepared high-risk
injectable medication (new)
5. Maladministration of
potassium-containing solutions (modified)
6. Wrong route
administration of chemotherapy (existing)
7. Wrong route
administration of oral/enteral treatment (new)
8. Intravenous
administration of epidural medication (new)
9.
Maladministration of Insulin (new)
10. Overdose of midazolam
during conscious sedation (new)
11. Opioid overdose of an
opioid-naïve patient (new)
12. Inappropriate administration of
daily oral methotrexate (new)
13. Suicide using
non-collapsible rails (existing)
14. Escape of a transferred
prisoner (existing)
15. Falls from unrestricted windows
(new)
16. Entrapment in bedrails (new)
17. Transfusion of
ABO-incompatible blood components (new)
18. Transplantation of
ABO or HLA-incompatible Organs (new)
19. Misplaced naso- or
oro-gastric tubes (modified)
20. Wrong gas administered
(new)
21. Failure to monitor and respond to oxygen saturation
(new)
22. Air embolism (new)
23. Misidentification of
patients (new)
24. Severe scalding of patients (new)
25.
Maternal death due to post partum haemorrhage after elective
caesarean section (modified)
Contacts:
Department of Health
Phone: 020 7210 5221
NDS.DH@coi.gsi.gov.uk