Identifying policy levers to reduce never events: a comparison of three high-income jurisdictions

Bhatia D., Lynch M., Murmann M., Roerig M., Byrd J., Allin S., & Marchildon G.


Conference:
Annual Conference of the Canadian Association for Health Services and Policy (CAHSPR) 2021
Date: May 2021


Abstract


Background and objectives: Patient safety incidents are a leading cause of disability and death in high-income countries, with an estimated 1 in 10 patients harmed while receiving hospital care. Never events are serious patient safety incidents that are preventable through systemic efforts and therefore, “should never occur”. In this comparative study, we sought to describe promising policy levers aimed at reducing never event rates in three high-income jurisdictions.

Approach: We undertook case studies of three jurisdictions that have sustained low never event rates (England, Ireland, New Zealand), according to the recent Organization for Economic Co-Operation and Development (OECD) data. We searched academic and grey literature and interviewed 22 local experts in patient safety and quality improvement (England: n =11, Ireland: n = 4, New Zealand: n = 7) to identify key policy levers, defined as mechanisms available to decision-makers to influence system changes. We used an OECD typology of patient safety policy interventions, which builds on the Donabedian “structure-process-outcome” model for quality of care, to analyze and collate findings.

Results: National patient safety policy efforts first appeared on government agendas in the early 2000s, following public inquiries into high-profile incidents. The following key policy interventions were identified in the three countries: (1) legislating an independent patient safety authority, responsible for leading the policy agenda, harmonizing data, coordinating stakeholders, and scaling up clinical initiatives; (2) increasing healthcare provider accountability through regulation, including through health ombudsmen, independent accreditation agencies, and professional self-regulatory bodies; (3) improving health system transparency and learning through never event reporting and publication of performance data, (4) facilitating open disclosure to patients and caregivers through apology protection laws and no-fault compensation schemes; and (5) routinely engaging patients and the public in patient safety initiatives through taskforces and co-design principles.

Conclusion: Multiple jurisdiction-wide approaches that prioritize accountability and transparency of systems, reduce blame on individual healthcare providers, and engage patients and caregivers hold promise in reducing never event rates. Empirical evidence is needed to understand how policy levers affect long-term safety outcomes, healthcare provider behaviour, and health system complexity.

Poster designed by Dominika Bhatia and Monika Roerig.

View the poster in Research Gate