The National Patient Safety Agency’s chief executive Martin Fletcher said: ‘We are working on a concept called Never Events, where we identify a set of events which are potentially catastrophic but highly preventable.There should be some financial consequence for unsafe care’
Officials told Parliament’s health committee that reporting of Never Events would start in 2009/10, with financial penalties being imposed by PCTs the following year.
NHS medical director Professor Sir Bruce Keogh, said: ‘In second year we anticipate that PCTs won’t pay for those never events – that will be the key lever.’
Dame Christine Beasley, Chief Nursing Officer for England, told Nursing Times: ‘We will look at the data we get in the first year and see what’s the best way to penalise for never events. We don’t want to do things that may destabilise the system or have any unintended consequences.’
Extra bed days needed to clear up the consequences of a major mistake may be one thing that PCTs refuse to fund. However, Mr Fletcher pointed out that in the case of a psychiatric patient absconding, this would not be the most appropriate penalty.
The proposed never events are:
1 Wrong site surgery,
2 Retained instrument post-operation,
3 Wrong route administration of chemotherapy,
4 Misplaced nasal or orogastric tube not detected prior to use,
5 Inpatient suicide using non-collapsible rails or while on one-to-one observation,
6 Absconding of transferred prisoners from medium or high secure mental health services,
7 In-hospital maternal death from postpartum haemorrhage after elective Caesarian section,
8 IV administration of concentrated potassium chloride.