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CQC looks to cut number of never events

How easy will it be to enforce universal rules?


The Care Quality Commission has warned that clinical autonomy is being put above patient safety in the health service and the number of never events is not falling.


In an attempt to reduce these events, which can include mistakes such as operating on the wrong part of the body, the regulator is proposing that clinicians follow a set of standardised, universal operating procedures.


The proposal follows an ongoing inquiry by the commission into why the number of these events remains high. Between April 2017 and March 2018, 469 incidents were reported in the health service.


The inquiry found an everyday culture and practice in the NHS of failing to reflect the high-risk nature of healthcare, according to Health Service Journal.


Although professional autonomy is important to allow clinicians to deal with complexities, said the inquiry, it is all too often prioritised at the expense of proven safety protocols and policies.


The proposed protocols would likely be around the issues of patient identification, consent, surgical site confirmation, implant identification and imaging and record keeping, according to the commission.


Evidence-based use of the most appropriate, safe and cost-effective implants could be more standardised than at present, found the inquiry, such as the type of mesh or joint replacement.


Training for all staff may need to change to ensure safety is fully embedded, said the report.


Further information

Health Service Journal: CQC proposes universal rules to cut ‘never events’

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