Abstract: Never Events are patient safety incidents that can cause harm or death and are so named because policy makers argue there is enough evidence available about how to prevent them, so they should never occur. Never events include wrong site surgery, wrong route drug administration, retained foreign objects and wrong implants. Between April-November 2017 332 Never Events occurred in hospitals in England, indicating that solutions to prevent them are not working. Although Resilient Healthcare is often described as a paradigm shift in safety management it is not clear how it can contribute to the investigation of adverse incidents. Root Cause Analysis (RCA) is currently used for the investigation of Never Events, but recent studies have found the recommendations to be of low quality. There is little incentive, time or resources for healthcare organisations to consider other approaches and little work has been done on how to use Resilient Healthcare insights to augment Safety I practices such as Root Cause Analysis. In this presentation the results of an analysis of 39 Never Events that occurred at one hospital over a two-year period will be discussed. The focus will be on the new insights and perspectives that Resilient Healthcare can offer to improve learning from Never Events. Recommendations for strengthening RCA and learning from Never Events will be discussed.
Biography: Janet Anderson is Director of the Centre for Applied Resilience in Healthcare and a Reader of Healthcare Improvement at King’s College London. She is a human factors psychologist. Her research draws on psychological and organisational theories and knowledge and is focused on designing systems to support safe human activity. She has specialist expertise in the theory and practice of organisational resilience, system modelling using cognitive work analysis, incident reporting and adverse event analysis, and inter professional teamwork. Board level processes and hospital wide systems for improving quality are an area of current research.