Annual Report & Accounts 2010/11 - James Paget University Hospitals

Never Events
Never Events are serious, largely preventable patient safety incidents that should not occur if
the available preventative measures have been implemented.
The core list of Never Events for 2010/11 is detailed. This has been increased to a list of 25
for 2011/12:
• Wrong site surgery
• Retained instrument post-operation
• Wrong route administration of chemotherapy
• Misplaced naso or orogastric tube not detected prior to use
• Inpatient suicide using non-collapsible rails
• Escape from within the secure perimeter of medium or high secure mental health
services by patients who are transferred prisoners
• In-hospital maternal death from post-partum haemorrhage after elective caesarean
section
• Intravenous administration of mis-selected concentrated potassium chloride.
The Trust has introduced a number of control measures to prevent Never Events from
occurring. However, during 2010/11 there were two Never Events, both of which involved
the retention of a small swab following suturing after an instrumental vaginal delivery. A
detailed programme of training, awareness and checklists has now been introduced to
prevent a similar occurrence in the future. An audit will be conducted during summer 2011 to
ensure these improvements have been embedded into practice.
Case Study: Patient Fall (SUI)
Incident: Patient found on the floor beside the bed having been recently transferred from
the admissions unit (within one hour of transfer). Patient was diagnosed with a fractured
neck of femur (broken hip). The family were informed and the incident was investigated
formally using Root Cause Analysis techniques.
Findings: Patient was transferred into the ward at lunchtime when staff were busy with
medicine administration and feeding patients, hence all falls prevention options were not
considered upon admission.
Improvements:
Patients at high risk of falls are now cohorted into one bay and staff are allocated to monitor
the patients (additional staff are booked).
Staff are encouraged to consider the use of falls prevention equipment such as falls beds
and sensocare equipment.
Falls risk assessments are conducted on admission and then weekly; each bay has an
allocated day for the assessment to be completed which is advertised at the end of each
bay.
James Paget University Hospitals NHS Foundation Trust
Quality Account 2010/11 Page 42 of 62