Abstract
Never events (NEs) are serious preventable patient safety incidents and are a component of formal quality and safety improvement (Q&SI) policies in the United Kingdom and elsewhere. A preliminary list of NEs for UK general practice has been developed, but the frequency of these events, or their acceptability to general practitioner (GPs) as a Q&SI approach, is currently unknown. The study aims to estimate (1) the frequency of 10 NEs occurring within GPs' own practices and (2) the extent to which the NE approach is perceived as acceptable for use. General practitioners were surveyed, and mixed-effects logistic regression models examined the relationship between GP opinions of NE, estimates of NE frequency, and the characteristics of the GPs and their practices. Responses from 556 GPs in 412 practices were analyzed. Most participants (70%-88%, depending on the NE) agreed that the described incident should be designated as a NE. Three NEs were estimated to have occurred in less than 4% of practices in the last year; however, two NEs were estimated to have occurred in 45% to 61% of the practices. General practitioners reporting that a NE had occurred in their practice in the last year were significantly less likely to agree with the designation as a NE compared with GPs not reporting a NE (odds ratio, 0.42; 95% CI = 0.36-0.49). The NE approach may have Q&SI potential for general practice, but further work to adapt the concept and content is required.
Highlights
If you ask older GPs you will find many of us who NE so rare it is not a useful measure of quality or is a historical 17 (24%) problem would have prescribed aspirin to under 12's in the 1980's
Never used adrenaline in 30 yrs clinical practice often the potential danger is that the ampule can be out of date when required Only a NE in surgery, remove home visit Add adrenaline should be within expiry date Clarify how critical the adrenaline is/what the emergency is Define "within minutes" It depends on ambulance availability in your town
Lots of results are abnormal, only a few are associated with life threatening or serious consequences
Summary
Needle stick injury due to sharps disposal failure Prescribing when adverse reaction recorded Abnormal investigation result is not reviewed specify age 16 not 12 to agree with guidelines; exclude topical treatments; replace aspirin with aspirin containing products e.g. Bonjela; make it clear that exceptions are permitted but should be documented justification e.g. by consultant for inflammatory arthritis etc. include 'taking' as well as prescribing eg due to lack poor explanation to patient; specify prescription is an error or incorrectly prescribed; specify prescribing occurs in general practice remove home visit as only a NE in surgery; add adrenaline should be within expiry date; clarify how critical the adrenaline is/what the emergency is; define "within minutes" add “recorded” as well as “known” to be pregnant; specify the level of teratogenicity and drug class; specify the type of clinical specialist; e.g. epilepsy mental health etc; note is acceptable if the benefits outweigh the risks; include drugs initiated prior to pregnancy add without IUS (eg Mirena); add “...in whom there is no regular monitoring for evidence of endometrial hyperplasia”; specify means oral as topical oestrogen may be used with an intact uterus; specify time scale e.g. more than 3m continuously or on repeat prescription; clarify timescale from last period and age > 50 as " period free” HRT is licenced; add “...unless under instruction by consultant Gynaecologist/Oncologist”; specify names of HRT products timescale is needed (delayed should be considered as well as missed); clarify referrer is in primary care; define level of suspicion e.g. to confirm rather than "suspect"; should really apply to any planned referral clarify emergency e.g. Is it 999 ambulance for an acute emergency?; specify how quick the response should be; add “...agreed as the most appropriate mode of transport” and “results in unnecessary delay or suffering”; specify who made the agreement - the GP/ practice admin staff/ ambulance service?; specify it is transport not arranged rather than transport not occurred; exclude psychiatric emergency admissions as secondary care arranges "appropriate" transport perhaps "accidental" might be more acceptable than "failure to follow guidelines"; include any needle stick/sharps injury; make clear is only in relation to the disposal of sharps; clarify systems failure vs simple accident (due to overflowing bin vs doing it to yourself) clarify severe adverse reaction vs. intolerance e.g. caused a severe proven documented adverse reaction which is potentially life threatening or the patient had a serious or anaphylactic reaction; define spectrum of allergy provide a timescale; specify clinically significant e.g. critically abnormal or life threatening; replace reviewed with actioned; the investigation should have been initiated by the practice (GPs receive unrequested results); remove abnormal because all results should be reviewed by a clinician. Needle stick injury due to sharps disposal failure Prescribing when adverse reaction recorded Abnormal investigation result is not reviewed specify age 16 not 12 to agree with guidelines; exclude topical treatments; replace aspirin with aspirin containing products e.g. Bonjela; make it clear that exceptions are permitted but should be documented justification e.g. by consultant for inflammatory arthritis etc. Prescribing Aspirin for a patient ≤ 12 years old (unless recommended by a specialist for specific clinical conditions e.g. Kawasaki’s disease)
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