Quality & Patient Safety

UK: NPSA releases list of eight mistakes that must never be committed by NHS

Patient Safety Monitor: Global Edition, March 17, 2009

The National Patient Safety Agency (NPSA) has composed a list of eight errors that National Health Service (NHS) hospitals should never commit. If hospitals commit any of these mistakes, deemed 'never events,' they will not be reimbursed for treatment, according to The Telegraph.

Some "never events" found on the list include physicians operating on the wrong side of the body, inpatients committing suicide using bed rails that do not collapse, patient escape from a medium or high security mental health service, and the death of a woman due to hemorrhage after a planned caesarean birth. The idea comes from a similar system used in the United States, which has helped reduce healthcare mistakes.

The government's chief medical officer, Sir Liam Donaldson, reports that 350 surgical errors are reported everyday, according to The Telegraph. The NHS will monitor and publically report how often the eight never events occur each year.

"The Never Events policy is a bold initiative designed to drive measurable improvements in patient safety," says Martin Fletcher, chief executive of the NPSA. "We've worked with the NHS to identify eight Never Events that are serious, largely preventable and have guidance available to prevent occurrence- healthcare providers need to ensure that this guidance is implemented."

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