What are "never events"? Not a term I'm familiar with.
'Never Events policy and framework
Revised January 2018
https://www.england.nhs.uk/wp-conte...d-Never-Events-policy-and-framework-FINAL.pdf
3.1 'Never Events are defined as Serious Incidents that are wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers.
Strong systemic protective barriers are defined as barriers that must be successful, reliable and comprehensive safeguards or remedies – for example, a uniquely designed connector that stops a medicine being given by the wrong route. The importance, rationale and good practice use of relevant barriers should be fully understood by and robustly sustained throughout the system, from suppliers, procurers, requisitioners, training units to frontline staff.'
3.2 'The Never Events policy and framework are designed to provide healthcare workers, clinicians, managers, boards and accountable officers with clarity on their responsibilities and on the principles of Never Events. In particular, these people should know what they are expected to do to prevent Never Events and how they must respond if they occur, including how they report a Never Event.'
3.3
'Never Events may highlight potential weaknesses in how an organisation manages fundamental safety processes and so this policy and framework provide the NHS with an essential lever for improving patient safety.'
3,4 NHS Improvement’s vision of high quality, compassionate and constantly improving healthcare requires us to nurture the necessary culture and conditions, including openness and transparency, evidence-based decisionmaking and a commitment to lifelong learning. As Don Berwick noted: “…standards, regulations and enforcement have a place in the pursuit of quality, but they pale in potential compared to the power of pervasive and constant learning.”
3.5
The Never Events policy and framework support our vision by requiring honesty, accountability and learning in response to a group of incidents that can be prevented if accepted practice (including available preventative measures) has been implemented.
3.6 In this context, it is important that when a Never Event occurs, regardless of the outcome, the problems in care are identified and analysed through full investigation using a systems-based investigation method (such as root cause analysis – RCA) to understand how and why they occurred (from a systems perspective), as described in the Serious Incident framework. This will mean effective and targeted action can be taken to prevent recurrence.'
3.7 Supporting staff to recognise Never Events is essential so that the opportunity to investigate, learn and improve can be identified in a timely way before vital information is lost.
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