Never events: the cultural and systems issues that cannot be addressed by individual action plans

摘要

Despite the term ‘never events’ these events continue to happen in the NHS. This paper considers thenfindings from a review of the causes of nine surgical ‘never events’; looking at the learning from theninvestigations to provide ‘a window on the system’ and considering the multiple issues that need tonbe addressed to reduce future risk. The paper discusses why many of the causes described inninvestigation reports cannot be adequately addressed by the action plans that target each individualncause — things are never that simple — instead the causes should be seen as a reflection of thencurrent state of safety within an organization, showing the underlying cultural and systems issues thatnneed to be addressed at a wider level than that of the incident itself.