Never Events: Patient Safety Protocol Failures

• Introduced in 2002 by the National Quality Forum (NQF) in the United States.

• Adopted in Western countries like the U.S., U.K., and Canada.

• Highlights the importance of preventing harm through systemic checks, improved processes, and strict adherence to safety protocols.

• The list of never events varies across organizations.

• The United Kingdom’s NHS’s updated 2021 list includes 16 events, while the United States recognizes 29 events.

• This variation reflects the complexity of healthcare as a socio-technical system.

• Healthcare providers should offer an apology, prepare a formal report, conduct a root cause analysis, and cover any costs incurred.

• The Leapfrog Group recommends specific steps to address the situation after a never event.

• The idea of completely preventing never events is a subject of ongoing debate.

• Never events persist at a rate of 1 to 2 per 100 incidents, with overall patient safety incidents occurring in 2 to 3 out of every 100 consultations.

• The concept of never events is criticized for concentrating accountability disproportionately on frontline healthcare workers.

• Never events have not been explicitly acknowledged or used in the Indian context.

• Similar incidents are categorised and addressed under the broader legal framework of medical negligence.

• Medical negligence occurs when a healthcare provider fails to meet the expected standard of care, leading to harm.