The latest HSIB report: advocating patient safety avoidance?

Following publication of the Healthcare Safety Investigation Branch’s (HSIB) report analysing ‘never events’ it is unfortunate to see a body which is supposed to be at the forefront of patient safety learning in essence advocating patient safety avoidance.

In essence, HSIB are accepting that some ‘never events’ simply cannot be prevented, but surely that is defeatist? The types of events we are talking about, e.g. incorrect hip surgery, and administering a drug incorrectly are absolutely preventable with basic adherence to the fundamental of clinical care to check what you are doing – that does not need a special environment in order to happen, it should be second nature; and if it’s not then that is absolutely an issue which needs to be addressed via training, better labelling of drugs and resources until it is resolved.

It seems a fundamentally flawed argument that something which keeps happening simply cannot be resolved – it is exactly those recurring issues which need to be solved? If we accept that it’s OK to get the fundamentals of healthcare wrong, how can we hope to develop a better NHS through patient safety learning which surely should be the aim of HSIB as the ultimate output of its work?