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31
Mar
Harrogate hospital launches review into serious but preventable patient incidents
Harrogate District Hospital has launched a review after recording 12 “never events” at the site.
In a report before the hospital’s board, Jonathan Coulter, chief executive of Harrogate and District NHS Foundation Trust, said the events were recorded over the last four years.
The health service defines a “never event” as “serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations”.
They can include incidents such as administration of medication by the wrong route, a retained foreign object post-procedure and an overdose of a substance such as insulin.
In his report, Mr Coulter said a “thematic review” had been launched following the never events.
He said:
The review has shown that learning from never events has not always been embedded trust-wide, meaning similar never events have taken place in subsequent years.
This has led to the need for safety recommendations/actions to be repeated on multiple occasions.
The Stray Ferret asked Harrogate and District NHS Foundation Trust what the nature of the “never events” were and whether the trust would be making any recommendations following its review to avoid any further incidents.
A trust spokesperson told us that they were unable to give specific details on the events as it “may compromise patient and staff confidentiality”.
They added:
Never events are healthcare incidents that should be preventable if strong protective systems and process are in place and are followed by staff.
The systems and process seek to minimise the impact of human factors on the ability to deliver high quality healthcare. Learning from what goes wrong in healthcare is crucial to preventing future harm, but it requires a culture of openness and honesty to ensure staff, patients, families and carers feel supported to speak up in a constructive way. We are committed to promoting a culture of learning and openness at Harrogate and District NHS Foundation Trust to maximise opportunities to keep our patients safe.
Each never event is fully investigated and recommendations are actioned. In any large organisation it can be challenging to embed the learning at every level.
We have recently commissioned a new programme of continuous improvement, known as ‘HDFT Impact’ which we are now utilising to further share and embed learning from incidents when things don’t go as planned, but also to share examples of high quality innovative healthcare.
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