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Ensuring the safety of everyone who comes into contact with health services is one of the most important challenges facing health care today.
The Department of Health in its recent White Paper, Equity and excellence: Liberating the NHS, puts safety services at the heart of its proposals. The supporting consultation document on the development of an outcomes framework also has patient safety as a key focus.
Improving patient safety involves assessing how patients may be harmed, preventing or managing risks, reporting and analysing incidents, learning from such incidents and implementing solutions to minimise the likelihood of them reoccurring.
Serious failures are uncommon. Where these occur, they are often due to weak systems rather than the fault of any one individual.
"Never events" are very serious, largely preventable patient safety incidents that should not occur if the relevant preventative measures have been put in place.
The Government proposed in last year's White Paper to expand the current list of incidents considered to be "never events". A draft list of "never events" was published in October 2010 and comments were sought on the proposals. Following this engagement process, the list was revised and the policy clarified. This paper therefore sets out the final expanded list for use in the NHS in 2011/12 and provides further guidance for how the "never events" policy should be implemented.
There are 25 "never events" on the expanded list. This includes the original eight events from previous years, some of which have been modified, and builds on the draft list published in October 2010.
This policy paper should be used in conjunction with the NHS Standard Contracts 2011/12.
The National Patient Safety Agency (NPSA) is a Special Health Authority created to co-ordinate the efforts of all those involved in healthcare, and more importantly to learn from patient safety incidents occurring in the NHS.
The Central Alerting System is a web-based system for issuing patient safety alerts and other safety critical guidance to the NHS and other health and social care providers. Safety alerts, emergency alerts, drug alerts, Dear Doctor letters and Medical Device Alerts are available on the CAS website. They are issued on behalf of the Medicines and Healthcare products Regulatory Agency (MHRA), the National Patient Safety Agency (NPSA), and the Department of Health. During 2010/11 full responsibility for the operation and management of CAS will transfer from the DH Patient Safety Branch to the NPSA.
