Poll question 1:
I get regular updates of all the Never Events/serious incidents in my organisation
- Yes 61%
- No 22%
- Don’t know 17%
Poll question 2:
My organisation shares the learning from Never Events/Serious incidents
- Regularly 60%
- Rarely 40%
- Never 0%
- Don’t know 0%
Poll question 3:
I have attended a Human Factors training course
- Never 39%
- Once in the past 5 years 39%
- More than once in the past 5 years 22%
Further information on this event, including the presentations, is available to NOA members in the Members Only Area of the website. (You will need to have registered for the Members Only Area to gain access)
You can keep up to date with upcoming webinars and other NOA activity by subscribing to our newsletter
Useful resources:
– Healthcare Conferences UK Masterclass: Learning from Never Events facilitated by Perbinder Grewal. Perbinder is also speaking at the Healthcare Conferences UK Serious Incident Investigation and Learning Virtual Conference
– GovConnect Improving Patient Safety & Care Conference, Collaboration for Better Care, 22nd of June 2022, Royal Society of Medicine, London
– NHS England Patient Safety – includes information on:
- Framework for involving patients in patient safety
- NHS patient safety incident management system (PSIMS)
- Patient Safety Incident Response Framework
- Serious Incident framework
- Never events data
- The Medicines Safety Improvement Programme
- National patient safety incident reports
- Data on patient safety alert compliance
- Revised Never events policy and framework
Never events and serious incidents are a cause for concern and anxiety when reported in an organisation. They require investigation and official reporting to the Care Quality Commission (CQC). The end result should be a process of open multidisciplinary analysis and discussion led by the Clinical Governance team that results in learning for the organisation. This process can be difficult and sensitive when harm is identified and errors attributed to processes and individual staff.
We are joined by Lecturer in Law, John Tingle from the University of Birmingham Law School who specialises in clinical negligence litigation and patient safety, and Mr Perbinder Grewal, a General & Vascular Surgeon, Human Factors & Patient Safety Trainer, and Emotional Intelligence Practitioner who leads on medical education both locally and nationally.