The Royal College of Obstetricians and Gynaecologists (RCOG) welcomes the publication of the Department of Health’s The ‘never events’ list 2011/12 today.
This document provides healthcare professionals with a definitive list of serious but avoidable patient safety incidents. Some of these ‘never events’ can be applied to any specialty, such as number 3: Retained foreign object post-operation; and doctors must take every precaution they can to ensure that these mistakes do not happen.
In particular, for maternity services, maternal death due to postpartum haemorrhage after elective caesarean section is identified as a ‘never event’ and both the RCOG and NICE have produced clinical guidelines to lower the incidence of postpartum haemorrhage after c-section. These should be followed to ensure that women undergoing a c-section recover well.
RCOG President Dr Tony Falconer said “Sometimes, accidents during surgery can occur due to human error and on other occasions they are the result of a complex train of circumstances. It is very distressing for the patient when they occur and healthcare professionals must remain vigilant and responsive. This updated list of ‘never events’ and the recently published NPSA surgical checklist for maternity should help to minimise these incidences.
“The RCOG will continue to work with the Department of Health and the NHS to ensure that lessons are learned and good systems are in place so that women get safe and good quality care.”
24 February 2011
Department of Health The ‘never events’ list 2011/12. The policy framework for use in the NHS, February 2011
Royal College of Obstetricians and Gynaecologists Green-top Guideline (no. 52) Postpartum Haemorrhage, Prevention and Management, November 2009
National Institute of Health and Clinical Excellence Clinical Guideline (CG13) Caesarean Section, April 2004
National Patient Safety Agency, WHO surgical safety checklist: for maternity cases only, November 2010
World Health Organization, Safe Surgery Saves Lives. The second global safety challenge, 2009