The Bugaboo of the “Never Event”

This is one of the better articles I’ve read recently about the flawed concept of the “never event.”

The name is the first flaw – “never” is a poor word, implying that when such an event occurs (and it will) it must be due to failure on the part of the care system. “Never” is a pejorative term that ultimately restricts the development of introspective self-regulation at the system level, leading to guilt and shame within the hospital culture and the temptation to blame the individual at the sharp end.

The assumption of tangibility is the second flaw – as the authors point out, the numerator in the ratio changes as a function of how “never events” are defined. Since these events are constructs, cognitively pieced together after the fact, the boundaries separated these events from all other adverse events are fuzzy and shifting. But the denominator is also a problem – how exactly is an opportunity for the “never event” operationalized? Regardless of what we do to event counts, we can also “cook the books” by expanding the definition of what an “opportunity” is, inflating the denominator without a requisite change in the numerator. Our numbers look better, but the events are still there.

The authors state that, in their systems, they look beyond the singular concept of the “never event” and seek to understand adverse events as a whole, regardless of their artificial designation. By doing so, they show empirically-validated improvements in adverse events without arguing whether something should never happen.

If we truly want to advance safety, we must abandon a priori classifications of errors based on whether we feel that they should (or should not) occur frequently. This limits our problem solving ability and ultimately constrains our creativity as a discipline.

Safety News – April 10

Interesting article regarding the FAA’s scolding of UAL/Continental linked here. It is a good example of how one set of activities that are normal to business in so many ways (i.e., retirement, new hiring, etc.) can be easily scapegoated when regulations are violated. How much of the “problematic behavior” highlighted by the FAA might be due to power struggles between the union and the company? This is a potential side effect of bureaucratic safety – regulatory oversight forces some bad behaviors out while decreasing corporate adaptability and providing opportunities for employees to use safety as a means to achieve other ends. Solution? More training and oversight. There is much we don’t know, obviously, but this smells like good old Newtonian “broken parts” mentality.

Meanwhile, in another industry, we get the distinct scent of “system drift,” the gradual acceptance of abnormality as normal. PG&E will pay $1.6B in damages for the San Bruno gas explosion in 2010. The article targets “safety failings by the utility and lax oversight by state regulators,” suggesting inter-organizational drift that was likely fueled by years of drifting toward a riskier mode of operation and rooted in factors that had nothing to do with safety – motivation, costs, staffing, etc.

Punishing the “bad guys” still plays well in the papers, though. I wonder how much UAL and PG&E will actually learn? Or will they just be motivated to find sneakier ways to do what they want?



In my discipline (organizational psychology), we have studied for some time the issue of “counterproductive work behaviors.” These are activities that employees generate for the purposes of harming the organization in some way. Typical examples might include theft, sabotage or abuse of breaks and lunch hours, but in other forms of the phenomenon another employee might be the target of the counterproductive behavior. Organizations often act as breeding grounds for individuals to use social power against one another in order to enhance or preserve their own statuses, and those who do not enjoy structural power in the organization may find themselves suffering at the hands of those that do.

The attached article addresses what the authors call “bullying”, which appears to be a new organizing label attached to behaviors that have been discussed in patient safety for some time. Nurses have long reported that doctors treat them poorly, pharmacists have long complained of marginalization, and administrators have long been vulnerable to perceptions among employees of mistrust, aloofness, and arbitrariness in punishments. Remedies are suggested, such as improving communication skills, decision making, and advocating for collaboration. Leadership and staffing are also identified as factors that contribute to “bullying.”

However, there are many nuances to how power differentials play out in organizations that are not addressed. For example, “bullies” in organizations are often not out to harm anyone, but to preserve  their own position and self-perception. Have hospitals considered what structural and cultural norms are in place to encourage those with power to be so hesitant and fearful about sharing it? Teaching the appropriate skills is a wonderful idea, but skills are just tools that one has to be motivated to use.

Hope you enjoy the article, and comments are welcome.