It had been a tough weekend for our colleagues. They had to deal with a complex patient in cardiac arrest. Yet the response team took days to get to them. This decline was hardly a surprise, the warning signs were there in the notes months before. Chronic ill health, previous missed opportunities to intervene with a failure to engage with difficult palliative care conversations. Had the case been examined in detail, a DNAR decision would probably have been in their best interests. Yet instead, there was a mad scramble to treat all reversible causes while the team tried to keep blood flowing through the system at short notice.
This may sound a sadly familiar story, but we are not talking about a patient. We are not even talking about a human. We are talking about a sudden break in the critical physical infrastructure of a hospital that was predictable, should have been prevented and responded to without the necessary skills nor urgency. As the NHS creaks into its 71st year, hospitals up and down the country will echo these events. Cables will break, pipes will burst, and lifts will stop. These are all predictable events. The important thing is that prevention can work and a rapid response should be rehearsed. The day of the week, the time of night or the hospital manager on duty should not matter just as it does not for patients when they are sick. A sick hospital means that all patients are at risk and a proportionate response should be elicited.
In 2009 the NHS implemented a “never events” policy to improve patient safety. The list of never events included wrong site surgery, in-patient suicide, and wrong route medications. It was hoped that this list would allow focus on detection, investigation and action with reports shared with care commissioners. It has long been taught that before offering help, you should first “check the scene is safe”. The physical structure of a system is a core component of safety for both patients and staff. It is about time that never events are extended to organisational events and non-clinical staff.
We propose that the never events list should include:
- Malfunctioning safety systems during an event such as fire detectors, sprinklers and circuit breakers.
- An inadequate or untimely response to critical infrastructure systems failure including water, electricity and transport.
- Serious injury to staff from known, predictable risks including asbestos exposure, non-compliant building regulations or structural damage.
- Failure to address staffing gaps that are known about that result in patient or staffing harm.
If it is right to call proximal patient harms events that should never happen, then surely it is right to apply these same standards to the wider hospital structures that endanger the many as well as the few.
Tom Holmes, Consultant in Intensive Care Medicine.
Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Research and Development lead in Critical Care at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @dr_mattmorgan. Matt’s first book, Critical—science and stories from the brink of life is available to order now www.drmattmorgan.com.
Competing interests: None declared