We are not alone as a country in facing acute patient safety challenges. Patient safety is a global as well as a national concern. The World Health Organization (WHO) recently published the Global Patient Safety Report, presenting important insights into the current state of patient safety across the world (WHO, 2024).
This considers progress on the patient safety calls for action made in the Global Patient Safety Action Plan 2021–2030 (WHO, 2021). The 2021 action plan set the scene with key ambitions and challenges for countries to meet, under a framework for action. It listed seven strategic objectives, each with five supporting strategies.
Global Patient Safety Report
The progress report from WHO offers important insights into strategies adopted, trends, issues, challenges, opportunities and so on. This will be a key resource for all stakeholders in patient safety – policy makers, health professionals, educators, patient advocates, researchers and so on. It is always useful to reflect on what other countries are doing in patient safety policy development and practice, to see what is working and what is not. That way, we can avoid reinventing the wheel and save valuable healthcare resources.
At 354 pages, there is a lot of detailed information to unpack in the progress report. Sections and themes include burden of harm to the patient, financial and economic burden of unsafe care, policies to eliminate avoidable harm in health care, high-reliability systems, and safety of clinical processes. Key findings include the following:
‘A safety culture in health care is recognized as crucial by most countries, yet only a quarter of countries reported to have made efforts towards developing a culture of safety in health care facilities and services.
‘Although the significance of human factors in health care is increasingly being acknowledged globally, only around a quarter of countries have started to implement human factors principles in patient safety measures in clinical practice, use of medical devices, information technology solutions, and service delivery processes.’
There are many other detailed findings on matters such as patient and family engagement, and health worker education skills and safety.
‘The methodology of the report is grounded in the first ever global patient safety survey conducted by the WHO. This survey was a pivotal effort in assessing the implementation of the action plan across Member States.’
Unpacking key patient safety information in the NHS
I have frequently mentioned in my columns the dangers of patient safety information overload for staff in the NHS. The latest global patient safety report (WHO, 2024) is well-crafted, containing key information that will be of interest to all NHS patient safety stakeholders. It is, however, yet another report in a long line that need to be carefully unpacked, reflected on and appropriately applied. This will be all much easier said than done for busy NHS staff coping with other acute patient safety matters in often resource-constrained environments.
It is all about managing time and priorities with limited resources. As a discipline, patient safety is a rich one in terms of the quality of literature and information available.
Never Events
In the progress report there is also a discussion of Never and/or Sentinel events reporting, including these definitions:
‘Never events are particularly shocking medical errors – such as performing surgery on the wrong body part or wrong patient – that should never occur. Sentinel events are unexpected occurrences that result in death or serious physical or psychological injury, or the risk of such outcomes…’
It points out that:
‘There is a global trend towards recognizing the significance of never events, reporting them, investigating their root causes, learning from them, and taking corrective actions to enhance patient safety.’
Dropping the term ‘Never Event’
The description of Never Events above is a useful one for NHS England to consider in its current review of the Never Event Framework (NHS England, 2024a). There have been controversial calls to drop the Never Event title from some errors currently categorised as such, for example:
‘Safety recommendation R/2021/111: It is recommended that NHS England and NHS Improvement revises the Never Events list to remove events, such as those presented in this national learning report, which do not have strong and systemic safety barriers.’
Healthcare Safety Investigation Branch, 2021
So, even though the Never Event that happens accords with the WHO definition, in that it is ‘a particularly shocking medical error’, if there are ‘no strong and systemic safety barriers’ then it should not be termed a Never Event? This does not make sense, I have said before in previous columns that the term ‘Never Event’ has a common and well understood meaning. It describes an event that should never happen, a particularly shocking one. To say otherwise and to argue for the reclassification of the term is engaging in linguistic semantics. It is the idea behind the label that matters and not necessarily the label itself. Hopefully, the consultation on Never Events will take note.
Recent data in England
Keeping with the topic of Never Events is an update to data released by NHS England (2024b), a provisional publication of Never Events reported as occurring between 1 April 2023 and 31 March 2024. The report states that 370 Serious Incidents appeared to meet the official definition of a Never Event and had an incident date between 1 April 2023 and 31 March 2024.It lists 179 wrong site surgery Never Events, which include:
- Injection to wrong organ/structure: 26
- Wrong procedure: 13
- Wrong side/site procedure: 35
There are 81 retained foreign object post procedure Never Events, which include 15 cases where it was a surgical swab.
The report also lists the Never Events by healthcare provider. Three trusts have 10 Never Events recorded against them for this time period and one has 11.
The continued occurrence of Never Events in the NHS is a stark reminder of the need to keep the terminology we have and to strengthen efforts to develop a proper patient safety culture. These types of events are unforgivable by any measure of the word and should not be happening in a modern NHS.
HSSIB: Swabs and Never Events
To continue further the discussion, the Health Services Safety Investigations Body (HSSIB) recently investigated the issue of retained swabs following invasive procedures. The interim and investigation reports (HSSIB, 2024a;2024b) show major NHS patient safety failings that require urgent attention and resolution.
Interim report
The HSSIB as part of its wider investigation identified common themes in 31 serious incident reports occurring between September 2019 and September 2022, where a swab was unintentionally retained following an invasive procedure. Common characteristics identified from trust serious incident reports were analysed and these included, according to the interim report (HSSIB, 2024a):
- Responsibility for swab counts
- Communication of information about swabs
- Visibility of swabs
- The make-up of the operating theatre team
- The timing of the count and its confirmation at sign out
- The type and duration of the surgical procedure
- Professional culture and practice
- Distractions and interruptions
- Competing tasks
- Time pressure.
- Time of day
- Clarity of policies and procedures.
These themes are discussed, and another controversial safety recommendation made:
‘Safety recommendation R/2023/012: HSSIB recommends that NHS England incorporates the findings of this interim report into its review of the Never Events policy, with specific focus on considering removing retained surgical swabs as a sub-set of retained foreign object Never Events.’
The report found no ‘strong systemic barriers’ to prevent these type of Never Events and based on the current official NHS England definition of them recommended dropping them from the approved list.
A serious mistake
For the reasons I advanced earlier this would be a serious mistake and is an exercise in linguistic semantics. Leaving a swab inside somebody when it should have been removed is an event that the person on the street would say should never happen. WHO (2024) uses the term ‘particularly shocking medical errors’ and leaving a swab in a patient is just that. I would oppose this safety recommendation.
Investigation report
The second report (HSSIB, 2024b) builds on the earlier work and there is a detailed consideration of issues, such as factors associated with the count process, detectability of swabs placed in cavity during surgery, responsibilities in relation to swab reconciliation, risk reduction and acceptance of risk and so on. The report does a deep dive into the subject and makes several key findings, including:
‘There is no accountability framework, and it is unclear who owns the risk for retained swabs and reducing the risk for retained swab events to as low as reasonably practicable.’
Conclusion
Developing a proper NHS patient safety culture is never going to be an easy task and the same can be said about other countries efforts. WHO (2024) paints a mixed global picture and there are things to celebrate as well as negatives. The progress report advances the patient safety literature and creates a road map for change. It will need to be digested by the NHS and appropriately applied in an environment with an increasing number of publications competing for attention.
Never events are discussed in WHO (2024) and we can see some global trends. They continue to plague the NHS. We do need to be aware of reform suggestions and the ongoing NHS England consultation. I would argue that dropping some established categories because of lack of ‘strong systemic barriers’ would be a backwards step and not in the public interest.