Never Events in General Practice? A focus group study exploring the concept and the implementation of preventative initiatives

Talk Code: 
Rebecca Lauren Morris
Rebecca Morris (1), Aneez Esmail (1), Paul Bowie (2, 3) , Carl de Wet (4) and Stephen Campbell (1)
Author institutions: 
(1) University of Manchester, (2) NHS Education for Scotland, (3) University of Glasgow, (4) Logan Hyperdome Doctors


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.


Five focus groups with General Practitioners (n=25) 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 implementation of approaches to prevent Never Events within routine practice. Analysis was thematic and underpinned by Normalization Process Theory.


While the Never Events approach was considered to be complex, participants identified a range of initiatives that aligned with approaches to improving the safety and quality of care. Implementation of preventative Never Event initiatives will need to consider the implications for consultations, embedding the approach within a learning system, 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. A whole systems approach to implementation within a practice was considered key to successful implementation of patient safety initiatives.


The Never Event concept is relatively new but considered overall an important approach to help address key primary care patient safety issues. 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 of everyday practice and the implementation of interventions to address patient safety issues in Primary Care and has implications for the commissioning of services.

Submitted by: 
Rebecca Lauren Morris
Funding acknowledgement: 
This study was funded by the National Institute for Health Research Greater Manchester Primary Care Patient Safety Translational Research Centre. The views expressed in this article are those of the authors and not necessarily those of the NHS, NIHR or the Department of Health.