19th February 2016

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Prof Sir Mike (Deep-Diver) Richards - CQC
In conversation with Roy Lilley - King's Fund March 1st, 5.30pm
Last night there were only 6 tickets left  HERE

News and Comment from Roy Lilley
"Never Events are serious incidents that are wholly preventable as guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers."
... that's what the NHSE web-site tells us.  There are 16 pages of 'guidance' telling us what never-events are.  I can save you the trouble. 
Basically: leaving stuff in, leaving stuff out; putting the right stuff in the wrong person, hence it becomes the wrong stuff; doing the wrong stuff, or doing the right stuff with the wrong person, hence it becomes the wrong stuff.  Poking the right bits in the wrong places.  Administering the wrong stuff, too much stuff or not enough stuff, falling out of windows or getting trapped in a bed.  Not rocket science.
Whatever it is, it's a nasty dangerous business.  In the past four years it has happened 1,100 times... or might have done.  The rules about what constitutes a 'never' act changed in 2015 and this count goes back to 2012.  Whatever, it's too many.
Five a week.  One a day... or not, depending if we are talking a 7-day NHS... and we're not coz we are all fed up with that.
Katherine Murphy, chief executive of the Patients Association, immediately climbed onto her high-horse and said: "It is a disgrace that such supposed 'never' incidents are still so prevalent."
She added: "These 1,100 patients have been very badly let down by utter carelessness..."
She is right to denounce them.  But, 'Prevalent'?  Mmm.  There were 9,920,000 procedures and interventions carried out last year.  By the way; up by 45% on the preceding year.  I make that 190,384 a week or 38,076 a day.
Now, before you reach for the green ink and write to me, I am not excusing, justifying, defending or tolerating bad practice, sloppiness, laziness, idiots or crooks.  I'm just trying to get my head around it all.
I understand; never, means never.  

However, just how bad is a one in 38,076 chance of something going wrong?  If we turn to Altman for a relative risk calculation; assuming never means never and zero is what we want (in 38,076 procedures) and we get one, the relative risk is 2.9999.  Again. Don't write to me; I know this is not quite the right calculation; however dealing with chance error is a balancing act between small available data and precision.
We might do better to look overseas for comparisons.  At the US Mayo Clinic they found never-events occurred in 1 of every 22,000 procedures but the US national rate is closer to 1 in 12,000 procedures.  In England, as we have seen, it's around 1 in 38,000.
Of course, these numbers become all too real when they are people, and loved ones.
Operating theatres are now using the WHO check-lists an approach borrowed from airlines.  Meanwhile, airlines are reducing their reliance on check-lists as they've got too long, tedious and pilots lost focus.
The Mayo study talks of the 'overconfidence of doctors' and nurses and at the other end of the scale; 'a focus on the minute details loses sight of the big picture'.  Complicated, eh?
It seems to me there is something wrong with the notion of a 'never' event.  We are kidding ourselves; they are not 'never', they are happening.  Perhaps we need 'always' events.
We 'always' want strategies that improve the outcomes of care.  Always want comprehensive and accessible data and records.  We always use standardised and universal approaches to care.  We always want great training and better communications, assertiveness, team working and time for debriefings.  Always use succinct and clear check-lists and always, always speak up if we see something going wrong.
I'm not so sure reaching for the language of 'disgrace' and 'carelessness' adds anything.  Better the language of 'why' and 'how' and 'solutions'.
These dreadful incidents will be tragedies for the families and a lesser tragedy, but a tragedy non-the-less, for the clinical leaders and teams involved.
I think we can say we will always strive to do better,always find out the gaps, the loops, the interfaces, the errors, mistakes, system failures and always dig-out why stuff goes badly wrong.
But, we can never say never.
Have a good weekend. 
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Health Chat
Prof Sir Mike Richards
Chief Inspector of Hospitals 
1st March 2016
King's Fund 5.30pm
A few tickets left
This is what I'm hearing;
if you know different,
tell me here
>>  I'm hearing - Rob Webster is leaving the Confed to run a Trust; good luck to him.  He knows what good looks like, now he has a chance to deliver it.  We wish him well.  He did a great job for the Confed.
>>  I'm hearing - Bob the Builder has got his dream job, when he leaves running UCL he is off to run Prop-Co.
>>  I'm hearing - the DH i embarking on a daft idea for another league table; to measure openness and honesty in reporting.  I hope the Trusts don't diddle the numbers!
>>  I'm hearing - troubled SE CSU is losing Nick Relph, the boss.  New ma is apparently an expert in freight shipping...
>>  I'm hearing - there is a delay in developing CCG rating; daft idea, anyway.
Need inspiration, a good idea or solve a problem
Dr Rodney 
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