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Dr Messenger: Never say never

"The true story behind these events is often completely different"

The real surprise of NHS 'never events' is that they don't happen more often, says Dr Messenger

I’d be as annoyed as the next man if a surgeon removed my wrong testicle, say, or the medics injected me with amoxicillin despite my medic-alert bracelet highlighting my penicillin anaphylaxis. Systems should be in place, patients should be protected, disasters should be averted.

But what is it about these ‘never events’ that the media loves to highlight? Who decides on this arbitrary hierarchy of medical blunder and what is it based on? The gravity of the outcome? The simplicity of the preventive system? Or are incidents just pulled out of a hat? And why label them with something as emotive and judgemental as the word ‘never’? This 'that should never happen' attitude reduces incredibly complex issues to the opinionated certainty of The Bloke Down the Pub.

This, in turn, simply makes it irresistible for headline writers and commentators who want to wade in with their own polarised language. That’s why we heard the level of ‘never events’ being described as a "disgrace” by the Patients’ Association the other day, which does little for the morale of NHS staff like you and me.

Besides, the true story behind these events is often completely different. Take a completely trivial episode from yesterday – one that happens, daily, in every GP practice up and down the land. My patient was discharged from hospital. Her perindopril hacd been increased from 4mg to 8mg, so could I update her repeats, asks the discharge letter? What could be simpler? But is she taking 4mg x 2 or 8mg x 1? And if the former, and I switch her repeat to 8mg, might she inadvertently end up taking 8mg x 2 = 16mg? And might that lead to a ‘never event’ of an overdose that lands me and my patient in the local, or even national, papers?

That’s before any intervention from the pharmacy side, which might resolve everything or confuse matters further. So I make a couple of phone-calls and sidestep a potential cock-up. This is just one tiny incident among thousands that GPs, hospital doctors and pharmacists are dealing with daily.

The true miracle here is not that serious errors happen, it’s that they don’t happen far more often. That low error rate is the result of us working hard, carefully and with some sense of purpose – though the more we’re berated in the media, the more the diligence and sense of vocation gets knocked out of us. So maybe the headlines should be screaming about how, given the complexity of the system and the stress it’s under, the NHS is unbelievably safe. Yes, I know, they’d never write a headline like that – although you can never say never, can you?

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