News / Health
Concern at number of ‘never events’ happening during surgery
Questions are being raised as to why incidents in surgery that are so serious they are called ‘never events’ keep happening.
A dozen ‘never events’ occurred across Bristol, North Somerset and South Gloucestershire in the past year – including people having the wrong teeth surgically removed.
Julia Ross, who is chief executive of the clinical commissioning group (CCG) for the area, has now raised concerns that despite their name, these incidents are being reported each month.
is needed now More than ever
The most recent ‘never event’ was an incorrect lens replacement, although the majority of these incidents are related to dentistry.
Speaking at a meeting of the CCG’s governing body on Tuesday (May 1), Ross said: “Each month we see there’s another ‘never event’. I’m uncomfortable about this.
“They are called never events for a reason. How are we going to do it better?”
According to NHS Improvement – the body responsible for helping healthcare providers give patients consistently safe, high-quality, compassionate care – ‘never events’ elsewhere in the country have included surgical equipment being left inside patients, operations on the wrong limb, incorrect implants being fitted and the incorrect use of certain medicines.
Lisa Manson, the CGG’s director of commissioning, said: “The dental ‘never events’ tended to be related to supervised students, but the recent ones have been consultants.
“It tends to be around wrong tooth extraction. You can mark the bib so the correct tooth is taken out, but we are still having wrong tooth extractions.”
Governing body member Nick Kennedy said after the meeting: “Dental can be a high-risk environment for ‘never events’ because it’s not the same type of theatre environment you find for other surgical procedures.
“There is also an element of complexity in dental extraction that makes marking the surgical site more difficult.
“Everybody carries out safety briefings and these are an essential part of the process of avoiding never events. But there is always the potential for error, and that’s why it’s vital the process is rigorous and effective.”
The CCG carries out reviews after every never event to see what can be learned.
The meeting heard suggestions that mistakes in dental surgery can be caused by “distractions”.
A CCG spokesperson said: “We don’t know that dental staff make mistakes because of distractions in surgery, but the differences between dental and the acute theatre environment may mean that there is greater potential for distraction.
“The current review has been commissioned to help us understand this issue better and we look forward to reviewing its conclusions.”
Main photo thanks to Medical Illustration UK Ltd.
Stephen Sumner is a local democracy reporter for South Gloucestershire
Read more: Revealed: New wave of NHS cuts in South Gloucestershire
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