Never say never

A BBC investigation was revealed today highlighting that 750 patients have suffered after preventable mistakes in England’s hospitals over the past four years. The incidents, such as operating on the wrong body part or leaving instruments inside patients, are categorised by the Department of Health as “never events”. This means they are incidents that are so serious they should never happen.

We routinely consider risk in medical device development; risk being defined as the combination of the probability of occurrence of harm and the severity of that harm. In human factors we focus particularly on the severity of harm where there any opportunities for human error.

The reality is that hundreds of thousands of adverse incidents occur in the NHS despite fantastic advances in procedures, technology and patient safety checklists. Almost nothing is impossible and people will do things that they thought they never would do.

The BBC findings serve as a stark reminder that opportunities for human error must be taken seriously, especially if they are so serious they should never happen.

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