Key result
The risk of a surgical Never Event in English NHS trusts was 1 in 16,423 operations (95% CI 1 in 15,283 to 1 in 17,648), showing no meaningful association with other safety indicators.
Why the study?
What is the risk of surgical Never Events in English acute NHS trusts?
Observational
Yes
What is the risk of surgical Never Events in English acute NHS trusts?
Effect estimate: Risk 1 in 16 423 operations (95% CI 1 in 15 283 to 1 in 17 648)
Surgical Never Events are rare and not a useful metric to judge the overall quality of care at the trust level.
Never Events occur too rarely for trust-level benchmarking; leaves open their value as quality indicators and the need for alternatives.
Never Events are medical errors that are believed to be preventable with appropriate measures. We surveyed all English acute NHS trusts to determine the number of surgical Never Events and surgical caseload for 2011-2014. There were 742 surgically related Never Events in three years, with no change in the number annually. The risk of a surgical Never Event was 1 in 16 423 operations (95% CI 1 in 15 283 to 1 in 17 648) or 1 Never Event per 12.9 operating theatres per year (95% CI 1 in 12.1 to 1 in 13.9). The risk of severe harm due to a Never Event was approximately 1 in 238 939 operations. There was no meaningful association between number of Never Events and other safety indicators. Surgical Never Events are undoubtedly important to individual patients, but they are not a useful metric to judge quality of care.
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Moppett et al. (2015) conducted an observational in Surgical Never Events. The risk of a surgical Never Event in English NHS trusts was 1 in 16,423 operations (95% CI 1 in 15,283 to 1 in 17,648), showing no meaningful association with other safety indicators.
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