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

AbstractWhy 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,’ especia lly 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 th e 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 practiceDespite 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 i...
Source: International Journal for Quality in Health Care - Category: International Medicine & Public Health Source Type: research