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RCPE Quality Governance Collaborative: Seminar Series
Seminar 3: Never Events - The Governance Implications
Quality Governance Collaborative Seminar on ‘Never Events – The Governance Implications’ on 25 May from 6:15pm – 7:45pm. This will be a virtually streamed event and all registrants will receive their joinning details the day ahead of the event.
This is the third seminar in a series of virtual governance seminars presented by the Royal College of Physicians of Edinburgh’s Quality Governance Collaborative. They are designed specifically for Chairs, Non-executive Directors and Executive Directors of Boards in health, social care and other institutions. The series will critically examine pertinent governance issues, which Chairs and Board members are obliged to address when discharging their corporate and clinical duties. The debates will allow the delegates to question and critique the presentations by experts (following the Chatham House rule). The QGC strongly encourages an open, fluid and diverse dialogue.
Discussion and Q&A - Please submit your questions to Slido.com using the code #RCPEGovernance
Event Overview
Never Events are defined as patient safety incidents that are “wholly preventable” because of strong and systemic barriers. The Never Event framework in England has evolved over time but there is no clear decrease in their occurrence over the last decade, equally there has been no increase in the understanding of the governance implications of such events by Board Directors.
Never Events are reported centrally and their incidence is published nationally which can make them a focus as a ‘safety measure’. There can also be a conflict caused by the description and their ongoing occurrence. More than 400 Never Events occurred in England in 2018.
The Healthcare Safety Investigation Branch – HSIB – investigates patient safety incidents, which occur across a system in NHS funded care in England. HSIB has carried out 10 investigations into the commonly occurring Never Events and these were analysed as a group looking at what theme promoted their occurrence and whether all of the listed Never Events truly meet the definition in the framework.
This Seminar has the following aims:
- To provide an introduction to Never Events and sentinel events
- To look at how these are defined and explore means of reducing safety incidents
- To critically examine why the governance of such events is not fully understood
- To introduce some of the investigations techniques used at HSIB
- To apply this knowledge to use in a frontline healthcare environment taking into account possible actions for boards, patient safety teams and clinical teams.
Chairs:
Prof Michael Deighan | Director of the Quality Governance Collaborative
Dr Catherine Labinjoh | Board member, Quality Governance Collaborative & Consultant Cardiologist
Speakers:
Dr Sean Weaver | Deputy Medical Director at Health Service Investigation Branch (HSIB)
Prof Cliff Shearman | Vice President Royal College of Surgeons of England