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That 468 ‘never events’ occurred in England from 1 April 2017 to 31 March 2018 is deeply depressing, but that I was involved in none of them allows me to observe from a safe distance.
Away from the spotlight, the temptation is to disassociate myself from these ‘never events’ - things I would never do - things so bad that I don’t even want to think about them.
The stigmatised ‘never event’ is unthinkable and unimaginable to most clinicians. It is something we naturally shrink away from. We hope it will never happen to us.
Unfortunately, bad things do happen to good people. ‘Never events’ almost always happen to good people trying to do good things, for seemingly good reasons. Good people who have been tripped by events rather than been unsteady on their feet. Good people still worthy of admiration and respect.
A culture of understanding the hazards associated with these trips needs to evolve. It falls to all of us to find and fill the holes in the ‘Swiss cheese’. We need a culture that promotes engagement, inclusion and focus, rather than disengagement, isolation and fear.
No competing interests
09 January 2019
Mark Davies, consultant in anaesthesia & perioperative medicine
Royal Liverpool & Broadgreen University Hospitals NHS Trust