Never Events – if it wasn’t so absolutely tragic it could be the stuff of black and white movies. Macabre slapstick. But it isn’t. It is incomprehensible.
How on earth, in this day and age, the era of technology, checklists, regulation and teamwork is it possible for catastrophes like this to happen.
How can a patient go into surgery to have their left leg amputated and wake up to find their right leg has been cut off by mistake.
Last year there were over 350 Never Events
People infused with the wrong drugs, given the wrong blood, had feeding tubes pushed into their lungs and drowned. It is an horrendous list.
These never events must be reported, listed, investigated and… and… and what? Do we learn from them? Apparently not. They keep happening.
They keep happening and the Secretary of State Jeremy Hunt wants to know why. And so do I.
What is it we’re not doing?
Jeremy Hunt’s solution is to ask the CQC to write a report, make a list of shame. It is probably the worst possible approach.
What we want to know is how to stop them happening, not to how to beat up the people where it has happened already.
At the Academy we do what is called passive collection. We sit back and provide a place for you to share all the best stuff you are proud of. And thank you for doing it!
However, as a one-off we want to change the approach for Never Events to active collection. We are inviting you to share your approach to never events and the innovations and good ideas and training that you have put in place to stop them happening.
Show us what good looks like. Tell us how you did it, what you are proud of. Share the good stuff. Show us what safe looks like.
By sharing ideas, not reinventing the wheel, we can save time, save money, save lives and celebrate success.
We are dedicating an whole new index and page to #FabSafe. Its easy to use. Upload up to 500 words, three pictures and as many links as you like.
We are already off to a flying start
We’ve given ourselves a target. Let’s see how much safer we can make the NHS in three months.
Hierarchies don’t work, we know that but networks do, let’s have the #Fab-Safe Network leading the way.
We are planning virtual network events and we’ll come, visit and look at the best of the best.
Together we can make a Fab-NHS safer.