The RCoA contributes to the Never Events Policy and Framework Review 2016/17

NHS England is conducting a review of its Never Events Policy and Framework. The RCoA has responded to this review, setting out the main issues on which it wishes to see change:

  • Changing the name from Never Events to Preventable Events in order to provide a clear signal that the focus is no longer on blame but on root cause analysis and learning from adverse events.
  • Conducting an external review of the Never Events programme in order to evaluate its effects on patient safety, and its impact on both patients and the healthcare workers involved.
  • Removing the financial penalties and tight time constraints imposed on Trusts in relation to Never Events to allow managers to focus on thoughtful investigation and making sustainable changes that improve patient safety.
  • Creating a national process whereby learning from Never Events can be shared between all Trusts.

Dr Will Harrop-Griffiths, RCoA Council Member said: “The College supports programmes that can be shown to enhance patient safety. However, its Fellows and Members are becoming increasingly concerned that the Never Events programme is in need of urgent change if it is to fulfil its goals of decreasing the incidence of adverse safety incidents. All too often, the focus is on blame and punitive investigations, which produce many “second victims” amongst doctors and other healthcare workers. The College will work with NHS England, the Royal Colleges and professional associations to change the Never Events framework into a system that works for patients and those who care for them, and acknowledges the importance of systems change, human factors and teamwork in advancing patient safety”.

You can read the full response here.

23 October 2016

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