Quality Measure: Never Events
Why this measure is important:
Never Events are serious, largely preventable patient safety incidents that should not occur if existing national guidance or safety recommendations have been implemented by healthcare providers. Each never event type has the potential to cause serious patient harm or death. However, serious harm or death is not required to have happened as a result of a specific incident occurrence for that incident to be categorised as a never event.
As the name suggests these events should never happen. If just one never event occurs it may well indicate serious failings in the safety management system of the organisation and would require robust investigation and action to avoid repeats.
How we measure:
We record all adverse events and examine these records to detect if any would be classified as a never event.
What we are doing to improve:
There is no need at present to improve this record but if a never event were to happen we would undertake a robust investigation and inform the CQC.