Never Events

Certain serious events that harm patients and are considered avoidable are referred to internationally as Never Events. A Swiss Never Events list and a national registry are intended to improve the handling of these avoidable events.

Until 2020, only a limited amount of information was available on how Never Events are dealt with in Swiss hospitals. The Foundation therefore conducted a survey among risk and quality managers in hospitals. The results showed that Never Events are considered important and occur rarely in individual institutions but are relatively common in the system as a whole. At the same time, the results also reveal very different approaches to this topic. They thus reflect the strong autonomy of individual hospitals in clinical risk management. To some extent, a certain discrepancy is also evident between the attributed importance of Never Events and the on-site procedure when a Never Event occurs.

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Strategic field of action

Never Events should become more central to measuring quality and patient safety in health care institutions. By means of a standard national definition and a Swiss list of Never Events, the aim is to create greater commitment and standardise the management of such events. At the same time, a national register should close an existing knowledge gap regarding the type, frequency and occurrence mechanisms of serious patient harm, as well as generating knowledge that helps to prevent Never Events from recurring.

Definition

Never Events are clearly identifiable, serious events related to clinical care, which have led to patient harm and could have been prevented with appropriately designed systems and/or targeted prevention measures. This definition classes the described events as particularly serious and preventable if the appropriate preventive measures are implemented. The occurrence of such events indicates weaknesses in prevention measures. They should each entail a system-oriented cause-effect analysis.

Never Event-List

In May 2020, the Foundation launched a project to create a nationally standardised Never Events list for Switzerland. This list serves as a learning tool for collecting and analysing data on the type, extent and accompanying circumstances of these serious events at local or national level. The aim is to use it to monitor developments, generate knowledge and improve system safety. The list is not intended for individual assessments or for rankings but, instead, to provide knowledge at national level that can then be used for prevention in the individual institutions.

1	Interventions	Intervention error
2	Interventions	Implantation of a wrong medical device
3	Transfusion/transplantation	AB0- or HLA-incompatible transfusion and transplantation
4	Interventions	Unintentional retention of foreign body
5	Medication	Misadministration of high-risk medication
6	Medication	Wrong administration of drugs
7	Medication	Too rapid administration og High-risk drug
8	Interventions	Metallic objects in the MRI magnetic field
9	General patient care	Burns and scalds
10	Interventions	Loss of biological material
11	General patient care	Damage due to patient restraint
12	Interventions	Feeding of a gastric tube whose incorrect position has not been ruled out

Recommendations

The Never Events list serves as a learning tool exclusively for collecting and analysing data on the type, scope and accompanying circumstances of such serious events at local or national level. The Foundation has formulated two key recommendations for the implementation.

Recommendation 1: Internal use in hospitals

The Never Events definition and the Never Events list are used in hospitals/hospital groups for internal patient safety management. This includes:

Establishing an internal reporting channel with recording of all defined Never Events
Basis for the prioritisation of risk management measures
Trigger criterion for internal case analyses