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FAQs about the Never Events Framework

 

  1. How were the Never Events selected for the core list?

  2. What is the number of Never Events reported to the NPSA’s Reporting and Learning System each year?

  3. Why have uncommon events been selected?

  4. How will Never Events be reported?

  5. Does the process cover independent sector provided, NHS funded care?

  6. Should processes that make up Never Events implementation take place for all Serious Untoward Incidents?

  7. Why does this framework not include reporting of incidence of Never Events in provider quality accounts?

  8. Why is the NHS Never Events list different from the United States list(s)?

  9. How will patients, service users or carers know if a Never Event has happened to them or their relatives?

  10. How can I get further support and guidance?

  11. Did you involve patients in the development of the Never Events policy?

     

 

Q. How were the Never Events selected for the core list?

 

The Never Events were chosen if they met the following criteria:

  • The Never Event may or does result in severe harm or death to patients or the public;
  • There is evidence that the Never Event has occurred in the past, that is it is a known source of risk (data sources: NPSA Reporting and Learning System and other Serious and Untoward Incident reporting systems);
  • There is existing national guidance and/or national safety recommendations on how the Never Event can be prevented, along with support for implementation;
  • The Never Event is preventable if national guidance and/or national safety recommendations are complied with;
  • Occurrence of the Never Event can be easily defined, identified and measured on an ongoing basis.

 

We used NPSA and other sources of data, expert opinion and national guidance to form a shortlist which was discussed with clinical experts and further refined based on feedback from the service.

The list of events developed through this method has a focus on acute care. We anticipate that, in future, the number and range of Never Events on the core list will cover a wider range of care settings.

 

Q. What is the number of Never Events reported to the NPSA’s Reporting and Learning System each year?

The numbers of Never Events reported to the Reporting and Learning System are small but there is evidence of under-reporting. A key aim of the first phase of Never Events implementation is to encourage accurate reporting to PCTs and the Reporting and Learning System. This will allow us to create a baseline for the future.

 

Q. Why have uncommon events been selected? Wouldn’t it be better to include more common events with lower severity?

Never Events are a subset of patient safety incidents that meet certain criteria for a specific purpose. They have been chosen to represent a breadth of outcomes that are potentially or actually severe. Implementation of the Never Events policy is just one part of wider safety improvement efforts, many of which have a focus on more common incidents. In subsequent years, more common events may be considered, to lever change.

 

Q. How will Never Events be reported?

PCTs will report local incidence of Never Events as part of routine quality and safety reporting and will publicly report annually on their incidence. In addition, the NPSA will publish national results on the number of Never Events reported to the Reporting and Learning System.

 

Q. Does the process cover independent sector provided, NHS funded care?

Yes.

 

Q. Should processes that make up Never Events implementation take place for all Serious Untoward Incidents?

Yes. The only additional requirement in the first phase of Never Events is for PCT boards to publicly report Never Event incidence. However, PCTs will need to ensure that processes for the reporting, investigation and communication of Serious Untoward Incidents are working correctly to allow this to happen. The NPSA is working on developing definitions and advice about Serious Untoward Incident reporting and investigation, and Never Events will fit clearly into this.

 

Q. Why does this framework not include reporting of incidence of Never Events in provider quality accounts?

The NPSA is discussing inclusion of reporting of Never Events as part of provider quality accounts with the relevant parties. We will keep you updated as discussions progress.

 

Q. Why is the NHS Never Events list different from the United States list(s)?

There are differences between the USA and UK in the policy for Never Events and the criteria for selection of Never Events reflects these differences. However, we did draw on lessons from the US experience when developing the UK’s list.

 

Q. How will patients, service users or carers know if a Never Event has happened to them or their relatives?

As with any patient safety incident, it is expected that providers will provide explanation and an apology for Never Events that occur. The Being open guidance explains the principles behind this approach.

 

Q. How can I get further support and guidance?

Visit the Never Events section for further information, guidance and tools. The resources we've provided should answer most of your questions, but we appreciate you may have additional ones. Please contact us with your question. We will ensure that the most appropriate member of the team gets in touch with you as soon as possible.

 

Your regional Patient Safety Action Teams (PSATs) can help to support good practice and root cause analysis training.

 

Contact your Strategic Health Authority for local PSAT details.

 

Q. Did you involve patients in the development of the Never Events policy?

We sought and received feedback from patient organisations and national patient safety champions during policy development.