Concept and Importance of Never Events
"Never events" are serious, largely preventable incidents in healthcare that should not occur if safety protocols are followed.
Introduced in 2002 by the National Quality Forum (NQF) in the U.S., the term emphasizes preventing harm through strict safety measures.
Examples include wrong-site surgeries, insulin overdoses, and mismatched blood transfusions, which can result in severe consequences like disability or death.
Variation in Definitions and Lists Across Organizations
Different organizations (e.g., NHS, Leapfrog, Cigna) maintain their own lists of never events, leading to variations in what is recognized.
The National Health Service (NHS), UK has 16 events on its 2021 list, while the U.S. recognizes 29 events.
This reflects the complexity of healthcare systems and the diverse factors influencing the occurrence and categorization of never events.
Addressing Never Events and Their Preventability
When a never event occurs, healthcare providers must apologize to the patient, report the event, perform a root cause analysis, and waive any costs incurred due to the incident.
While reducing the occurrence of never events is a priority, achieving complete prevention remains debated due to the complexity of healthcare systems.
The "As Low As Reasonably Practicable" (ALARP) approach suggests that while these events can be minimized, total prevention may not be practical.
Never Events in the Indian Context
In India, the concept of "never events" is not formally recognized, with incidents instead categorized under medical negligence.
Medical negligence, governed by the Bolam test, involves failure to meet expected standards of care, resulting in harm.
The distinction between medical errors, negligence, maloccurrences, and complications is important in understanding how such incidents are addressed legally.
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