What should never happen in General Practice? A focus group study exploring the concept of Never Events in General Practice and enablers and barriers to their implementation in practice.

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The problem

Patient safety in health care is now a global concern because of mounting evidence that patients unintentionally but frequently suffer preventable harm. In response, many countries have implemented national improvement strategies, which include polices to help prevent Never Events from occurring. Never Events are defined as patient safety incidents which are potentially serious and avoidable if suitable procedures were implemented by healthcare professionals. Systematic approaches to reduce their occurrence must therefore be identified and implemented. However, Primary Care clinicians' understanding of the concept and use of the term of ‘Never Events', the acceptability of implementing them in General Practice and the work that this will entail to embed them into routine practice are currently unknown.

The approach

Four focus groups with General Practitioners (n=36) from the North West of England and West of Scotland explored: (i) understanding and perceptions of the concept of Never Events in General Practice; (ii) what influenced individuals' capacity to deal with Never Events; and (iii) the required processes to embed and monitor the Never Events approaches within routine practice. Analysis was thematic and underpinned by Normalization Process Theory.


While the Never Events approach was considered to be complex and participants identified a number of potential limitations their potential for improving the safety and quality of care was identified. Implementation of Never Events will need to consider the implications for consultations, , adequate resource allocation and organisational support. Embedding Never Events into routine practice will require responsiveness to the range of potential Patient Safety indicators, the roles of different health care professionals and the logistical implications for the co-ordination of care.


Never Events is a relatively new but important approach to help address key primary care patient safety issues. Its implementation will require interventions that are responsive to the complexity of the General Practice setting. A whole systems approach may provide an optimal context for understanding the complexities involved and the implementation of interventions to address patient safety issues in Primary Care and has implications for the commissioning of services.


  • Rebecca Morris, NHS Education for Scotland, Glasgow, UK
  • Sudeh Cheraghi-Sohi, NHS Education for Scotland, Glasgow, UK
  • Aneez Esmail, NHS Education for Scotland, Glasgow, UK
  • Paul Bowie, University of Glasgow, Glasgow, UK
  • Carl de Wet
  • Stephen Campbell, NHS Education for Scotland, Glasgow, UK