de Wet Carl, O'Donnell Catherine, Bowie Paul
General Practice & Primary Care, Institute of Health & Wellbeing, College of Medical, Veterinary and Life Science, University of Glasgow, Glasgow.
Br J Gen Pract. 2014 Mar;64(620):e159-67. doi: 10.3399/bjgp14X677536.
The 'never event' concept has been implemented in many acute hospital settings to help prevent serious patient safety incidents. Benefits include increasing awareness of highly important patient safety risks among the healthcare workforce, promoting proactive implementation of preventive measures, and facilitating incident reporting.
To develop a preliminary list of never events for general practice.
Application of a range of consensus-building methods in Scottish and UK general practices.
A total of 345 general practice team members suggested potential never events. Next, 'informed' staff (n =15) developed criteria for defining never events and applied the criteria to create a list of candidate never events. Finally, UK primary care patient safety 'experts' (n = 17) reviewed, refined, and validated a preliminary list via a modified Delphi group and by completing a content validity index exercise.
There were 721 written suggestions received as potential never events. Thematic categorisation reduced this to 38. Five criteria specific to general practice were developed and applied to produce 11 candidate never events. The expert group endorsed a preliminary list of 10 items with a content validity index (CVI) score of >80%.
A preliminary list of never events was developed for general practice through practitioner experience and consensus-building methods. This is an important first step to determine the potential value of the never event concept in this setting. It is now intended to undertake further testing of this preliminary list to assess its acceptability, feasibility, and potential usefulness as a safety improvement intervention.
“零容忍事件”概念已在许多急症医院环境中实施，以帮助预防严重的患者安全事故。其益处包括提高医疗保健人员对极其重要的患者安全风险的认识、促进预防措施的积极实施以及便于事件报告。
制定一份全科医疗的零容忍事件初步清单。
在苏格兰和英国的全科医疗中应用一系列达成共识的方法。
共有345名全科医疗团队成员提出了潜在的零容忍事件。接下来，“见多识广的”工作人员（n = 15）制定了定义零容忍事件的标准，并应用这些标准创建了一份候选零容忍事件清单。最后，英国初级保健患者安全“专家”（n = 17）通过改进的德尔菲小组并完成内容效度指数练习，对一份初步清单进行了审查、完善和验证。
共收到721条作为潜在零容忍事件的书面建议。主题分类后减少到38条。制定并应用了五条全科医疗特有的标准，以产生11条候选零容忍事件。专家组认可了一份包含10项内容的初步清单，其内容效度指数（CVI）得分>80%。
通过从业者经验和达成共识的方法，为全科医疗制定了一份零容忍事件初步清单。这是确定零容忍事件概念在该环境中的潜在价值的重要第一步。现在打算对这份初步清单进行进一步测试，以评估其可接受性、可行性以及作为安全改进干预措施的潜在效用。
