NHS Hospital Has Four ‘Never Events’ in a Single Year

Kettering General Hospital (KGH) has apologised to a patient after they incorrectly administered medication to them, something known as a ‘never event’. The patient, who was being treated as an inpatient at the hospital, had a central catheter inserted to receive medication intravenously. However, a drug that should have been delivered orally was injected into the catheter while a drug that should have been injected was given orally.

KGH, part of the University of Hospitals of Northamptonshire NHS Trust, say that the patient received treatment immediately after the mistake was made and there was no harm caused as a result. As well as apologising, they have started an investigation into how the mistake was made.

A never event is so named because it should never happen. Healthcare culture usually accepts that mistakes can and do happen, and focuses on being candid about mistakes, and learning from them so the organisation can minimise the risk of them occurring again. However, never events are in a special category. Seen as both avoidable and with the potential for severe consequences, processes should be in place to ensure that such mistakes are never made and, ideally, cannot be made.

If a never event occurs, they must be recorded, reported, and investigated, and they are considered a serious issue by the senior management. This is the fourth never event at the hospital in a calendar year.

In February this year, a patient receiving oxygen managed to connect their tubing to a medical airflow meter rather than the supply. Although these were the actions of a patient, rather than medical staff, the hospital is responsible for ensuring the safety of patients, and the risks of disrupting oxygen supply are obvious.

This was followed in the summer by two incidents in the ophthalmology department. In July, a patient was given a Lucentis injection into the wrong eye, a procedure that could have serious side effects. In the following month, another patient was given an eye injection based on someone else’s scans, which had been incorrectly labelled.

The Healthcare Safety Investigation Branch issued a report in 2019 on incidents like this. Featuring a series of recommendations, they noted that in most cases there was little or no harm caused. However, they warned that there is the potential for medication-related never events to have lifelong adverse impacts, or even be fatal, in extreme circumstances.

It is, therefore, a concern that a single hospital has recorded four never events, including three medication errors, in a single year. And especially concerning that two occurred within the same department in a short space of time.

The hospital is currently investigating the incidents and learning from them. Although in these incidents there was no adverse harm to the patients involved, the investigation will focus on how the never event was possible, and what steps or changes need to be taken to prevent them. In 2020 KGH did not have any never events and will be hoping avoid any more in the rest of 2021.

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