Common general surgical never events: analysis of NHS England never event data

2021 ◽  
Vol 33 (1) ◽  
Author(s):  
Islam Omar ◽  
Rishi Singhal ◽  
Michael Wilson ◽  
Chetan Parmar ◽  
Omar Khan ◽  
...  
Keyword(s):  
Breast Implants ◽  
Skin Condition ◽  
Chest Drain ◽  
Event Data ◽  
Wrong Site Surgery ◽  
Wrong Side ◽  
Retained Foreign Body ◽  
Never Events ◽  
Never Event ◽  
Wrong Site

Abstract Background There is little available data on common general surgical never events (NEs). Lack of this information may have affected our attempts to reduce the incidence of these potentially serious clinical incidents. Objectives The purpose of this study was to identify common general surgical NEs from the data held by the National Health Service (NHS) England. Methods We analysed the NHS England NE data from April 2012 to February 2020 to identify common general surgical NEs. Results There was a total of 797 general surgical NEs identified under three main categories such as wrong-site surgery (n = 427; 53.58%), retained items post-procedure (n = 355; 44.54%) and wrong implant/prosthesis (n = 15; 1.88%). We identified a total of 56 common general surgical themes—25 each in the wrong-site surgery and retained foreign body categories and six in wrong implants category. Wrong skin condition surgery was the commonest wrong-site surgery (n = 117; 27.4%). There were 18 wrong-side chest drains (4.2%) and 18 (4.2%) wrong-side angioplasty/angiograms. There were seven (1.6%) instances of confusion in pilonidal/perianal/perineal surgeries and six (1.4%) instances of biopsy of the cervix rather than the colon or rectum. Retained surgical swabs were the most common retained items (n = 165; 46.5%). There were 28 (7.9%) laparoscopic retrieval bags with or without the specimen, 26 (7.3%) chest drain guide wires, 26 (7.3%) surgical needles and 9 (2.5%) surgical drains. Wrong stents were the most common (n = 9; 60%) wrong implants followed by wrong breast implants (n = 2; 13.3%). Conclusion This study found 56 common general surgical NEs. This information is not available to surgeons around the world. Increased awareness of these common themes of NEs may allow for the adoption of more effective and specific safeguards and ultimately help reduce their incidence.

scholarly journals EP.TH.25Common General Surgical Never Events: An In-depth Analysis of Never Events data held by NHS England

2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Islam Omar ◽  
Rishi Singhal ◽  
Michael Wilson ◽  
Chetan Parmar ◽  
Omar Khan ◽  
...  
Keyword(s):  
Breast Implants ◽  
Skin Condition ◽  
Chest Drain ◽  
Wrong Site Surgery ◽  
Wrong Side ◽  
Retained Foreign Body ◽  
Depth Analysis ◽  
Never Events ◽  
Events Data ◽  
Wrong Site

Abstract Background There is little available data on common general surgical NE. Lack of this information may have affected our attempts to reduce the incidence of these potentially serious clinical incidents. The purpose of this study was to identify common general surgical NE from the data held by the National Health Service (NHS) England. Methods We analyzed NHS England NE data from April 2012 to February 2020 to identify common general surgical NE. Results There was a total of 797 general surgical NE identified under three main categories of Wrong-Site Surgery (n = 427;53.58%), Retained Items Post-Procedure (n = 355;44.54%) and Wrong Implant/Prosthesis and (n = 15;1.88%). We identified a total of 56 common general surgical themes - 25 each in Wrong-Site Surgery and Retained Foreign Body category and 6 in wrong implants. Wrong skin condition surgery was the commonest wrong-site surgery (n = 117;27.4%). There were 18 wrong side chest drains (4.2%) and 18 (4.2%) wrong side angioplasty/angiogram. There were 7 (1.6%) instances of confusion in pilonidal/perianal/perineal surgeries and 6 (1.4%) instances of biopsy of cervix rather than colon or rectum. Retained surgical swabs were the most common retained items (n = 165;46.5%). There were 28 (7.9%) laparoscopic retrieval bags with or without the specimen, 26 (7.3%) chest drain guidewires, 26 (7.3%) surgical needles; and 9 (2.5%) surgical drains. Wrong stents were the most common (n = 9;60%) wrong implant followed by wrong breast implants (n = 2;13.3%). Conclusion This study found 56 common general surgical Never Events. Increased awareness of these common themes of NE may ultimately help reduce their incidence.

SP7.1.5 Common General Surgical Never Events: Analysis of NHS England Never Events Data

2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Islam Omar ◽  
Rishi Singhal ◽  
Michael Wilson ◽  
Chetan Parmar ◽  
Omar Khan ◽  
...  
Keyword(s):  
Breast Implants ◽  
Skin Condition ◽  
Chest Drain ◽  
Wrong Site Surgery ◽  
Wrong Side ◽  
Retained Foreign Body ◽  
Post Procedure ◽  
Never Events ◽  
Events Data ◽  
Wrong Site

Abstract Background There is little available data on common general surgical Never Events (NE). Lack of this information may have affected our attempts to reduce the incidence of these potentially serious clinical incidents. The purpose of this study was to identify common general surgical NE from the data held by the NHS England. Methods We analysed NHS England NE data from April 2012 to February 2020 to identify common general surgical NE. Results There was a total of 797 general surgical NE identified under three main categories of Wrong-Site Surgery (n = 427;53.58%), Retained Items Post-Procedure (n = 355; 44.54%), and Wrong Implant/ Prosthesis and (n = 15; 1.88%). We identified a total of 56 common general surgical themes - 25 each in the Wrong-Site Surgery and Retained Foreign Body category and 6 in wrong implants. Wrong skin condition surgery was the commonest wrong-site surgery (n = 117; 27.4%). There were 18 wrong side chest drains (4.2%) and 18 (4.2%) wrong side angioplasty/angiogram. There were 7 (1.6%) instances of confusion in pilonidal/perianal/perineal surgeries and 6 (1.4%) instances of biopsy of cervix rather than colon or rectum. Retained surgical swabs were the most common retained items (n = 165;46.5%). There were 28 (7.9%) laparoscopic retrieval bags with or without the specimen, 26 (7.3%) chest drain guidewires, 26 (7.3%) surgical needles; and 9 (2.5%) surgical drains. Wrong stents were most common (n = 9;60%) wrong implant followed by wrong breast implants (n = 2;13.3%). Conclusion This study found 56 common general surgical NE. Increased awareness of these common themes of NE may help reduce their incidence.

scholarly journals Analysis and outcomes of wrong site thyroid surgery

BMC Surgery ◽  
2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Gianlorenzo Dionigi ◽  
Marco Raffaelli ◽  
Rocco Bellantone ◽  
Carmela De Crea ◽  
Carlo Enrico Ambrosini ◽  
...  
Keyword(s):  
Thyroid Surgery ◽  
Rare Event ◽  
Lymph Node Excision ◽  
Legal Action ◽  
Preventive Strategies ◽  
Case Presentation ◽  
Wrong Site Surgery ◽  
Wrong Side ◽  
Low Volume ◽  
Wrong Site

Abstract Background In thyroid surgery, wrong-site surgery (WSS) is considered a rare event and seldom reported in the literature. Case presentation This report presents 5 WSS cases following thyroid surgery in a 20-year period. We stratified the subtypes of WSS in wrong target, wrong side, wrong procedure and wrong patient. Only planned and elective thyroid surgeries present WSS cases. The interventions were performed in low-volume hospitals, and subsequently, the patients were referred to our centres. Four cases of wrong-target procedures (thymectomies [n = 3] and lymph node excision [n = 1] performed instead of thyroidectomies) and one case of wrong-side procedure were observed in this study. Two wrong target cases resulting additionally in wrong procedure were noted. Wrong patient cases were not detected in the review. Patients experienced benign, malignant, or suspicious pathology and underwent traditional surgery (no endoscopic or robotic surgery). 40% of WSS led to legal action against the surgeon or a monetary settlement. Conclusion WSS is also observed in thyroid surgery. Considering that reports regarding the serious complications of WSS are not yet available, these complications should be discussed with the surgical community. Etiologic causes, outcomes, preventive strategies of WSS and expert opinion are presented.

Prevention of 3 “Never Events” in the Operating Room: Fires, Gossypiboma, and Wrong-Site Surgery

2010 ◽  
Vol 18 (1) ◽  
pp. 55-60 ◽  
Author(s):  
Hamid R. Zahiri ◽  
Jeffrey Stromberg ◽  
Hadas Skupsky ◽  
Erin K. Knepp ◽  
Matthew Folstein ◽  
...  
Keyword(s):  
Operating Room ◽  
Wrong Site Surgery ◽  
Room Fires ◽  
Never Events ◽  
Wrong Site

EP.TH.26Identification of Common Themes from Never Events Data Published by NHS England

2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Islam Omar ◽  
Yitka Graham ◽  
Rishi Singhal ◽  
Michael Wilson ◽  
Brijesh Madhok ◽  
...  
Keyword(s):  
Financial Burden ◽  
Skin Lesions ◽  
Intraocular Lenses ◽  
Hip Prostheses ◽  
Wrong Side ◽  
Common Category ◽  
Foreign Objects ◽  
Gastric Tubes ◽  
Never Events ◽  
Wrong Site

Abstract Background Never events (NEs) are serious clinical incidents that cause potentially avoidable harm and impose a significant financial burden on healthcare systems. The purpose of this study was to identify common never events. Methods We analysed the NHS England NE data from 2012 to 2020 to identify common never events category and themes. Results We identified 51 common NE themes in 4 main categories out of a total of 3247 NE reported during this period. Wrong-site surgery was the most common category (n = 1307;40.25%)) followed by retained foreign objects (n = 901;27.75%); wrong implant or prosthesis (n = 425;13.09%); and non-surgical/infrequent ones (n = 614;18.9%). Wrong-side and wrong tooth removal were the most common wrong-site NE accounting for 300 (22.95%) and 263 (20.12%) incidents, respectively. There were 197 (15%) wrong-site blocks, 125 (9.56%) wrong procedures, and 96 (7.3%) wrong skin lesions excised. Vaginal swabs were the most commonly retained items (276;30.63%) followed by surgical swabs (164;18.20%) and guidewires (152;16.87%). There were 67 (7.44%) incidents of retained parts of instruments and 48 (5.33%) retained instruments. Wrong intraocular lenses (165;38.82%) were the most common wrong implants followed by wrong hip prostheses (n = 94;22.11%) and wrong knees (n = 91;21.41%). Non-surgical events accounted for 18.9% (n = 614) of the total incidents. Misplaced naso-or oro-gastric tubes (n = 178;29%) and wrong-route administration of medications were the most common events in this category (n = 111;18%), followed by unintentional connection of a patient requiring oxygen to an air flow-meter (n = 93;15%). Conclusion This paper identifies common NE categories and themes. Awareness of these might help reduce their incidence.

Strategies to avoid wrong-site surgery during spinal procedures

2011 ◽  
Vol 31 (4) ◽  
pp. E5 ◽  
Author(s):  
Wesley Hsu ◽  
Ryan M. Kretzer ◽  
Michael J. Dorsi ◽  
Ziya L. Gokaslan
Keyword(s):  
Patient Care ◽  
Spine Surgery ◽  
Rare Occurrence ◽  
Wrong Site Surgery ◽  
Wrong Side ◽  
Wrong Site

Wrong-site surgery (WSS) is a rare occurrence that can have devastating consequences for patient care. There are several factors inherent to spine surgery that increase the risk of WSS compared with other types of surgery. Not only can a surgeon potentially operate on the wrong side of the spine or the wrong level, but there are unique issues related to spinal localization that can be challenging for even the most experienced clinicians. The following review discusses important issues that can help prevent WSS during spinal procedures.

scholarly journals Incidence of Neurosurgical Wrong-Site Surgery Before and After Implementation of the Universal Protocol

Neurosurgery ◽  
2012 ◽  
Vol 72 (4) ◽  
pp. 590-595 ◽  
Author(s):  
Jay A. Vachhani ◽  
Jeffrey D. Klopfenstein
Keyword(s):  
The United States ◽  
University Of Illinois ◽  
Persistent Problem ◽  
Wrong Site Surgery ◽  
Wrong Side ◽  
Before And After ◽  
The University ◽  
Universal Protocol ◽  
Wrong Level Spine Surgery ◽  
Wrong Site

Abstract BACKGROUND: Although exceedingly rare, wrong-site surgery (WSS) remains a persistent problem in the United States. The incidence is thought to be 2 to 3 per 10 000 craniotomies and about 6 to 14 per 10 000 spine surgeries. In July 2004, the Joint Commission mandated the Universal Protocol (UP) for all accredited hospitals. OBJECTIVE: To assess the effect of UP implementation on the incidence of neurosurgical WSS at the University of Illinois College of Medicine at Peoria/Illinois Neurological Institute. METHODS: The Morbidity and Mortality Database in the Department of Neurosurgery was reviewed to identify all recorded cases of WSS since 1999. This was compared with the total operative load (excluding endovascular procedures) of all attending neurosurgeons to determine the incidence of overall WSS. A comparison was then made between the incidences before and after UP implementation. RESULTS: Fifteen WSS events were found with an overall incidence of 0.07% and Poisson 95% confidence interval of 8.4 to 25. All but one of these were wrong-level spine surgeries (14/15). There was only 1 recorded case of wrong-side surgery and this occurred after implementation of the UP. A statistically greater number of WSS events occurred before (n = 12) in comparison with after (n = 3) UP implementation (P < .001). CONCLUSION: A statistically significant reduction in overall WSS was seen after implementation of the UP. This reduction can be attributed to less frequent wrong-level spine surgery. There was no case of wrong procedure or patient surgery and the 1 case of wrong-side surgery occurred after UP implementation.

scholarly journals Making the Operating Theatre a 'High-Reliability' Environment

2012 ◽  
Vol 94 (5) ◽  
pp. 159-161
Author(s):  
Bryn Baxendale ◽  
Bryony Lovett
Keyword(s):  
Patient Outcome ◽  
High Reliability ◽  
Surgical Care ◽  
Operating Theatre ◽  
Public Healthcare ◽  
High Quality ◽  
The Public ◽  
Wrong Site Surgery ◽  
Never Events ◽  
Wrong Site

The public, healthcare commissioners and regulators rightly seek assurances about delivery of reliable, high-quality surgical care. The Department of health's 'never events' framework 1 specifically lists patient misidentification, wrong-site surgery and retained swabs and instruments as unacceptable occurrences. Professional conversations reveal many seemingly inconsequential daily occurrences that have an impact on patient outcome and ongoing management. Unfortunately, many of these incidents are not reported formally by those involved, which limits the opportunity for professionals and organisations to learn from subsequent analysis.

scholarly journals A History of Wrong Site Surgery in Rhode Island

2008 ◽  
Vol 94 (4) ◽  
pp. 6-10
Author(s):  
Robert S. Crausman ◽  
Bruce McIntyre
Keyword(s):  
Patient Safety ◽  
Rhode Island ◽  
Critical Role ◽  
Wrong Site Surgery ◽  
Wrong Side ◽  
History Of ◽  
The Individual ◽  
Safety Systems ◽  
Wrong Site

ABSTRACT Wrong site, side and patient surgeries continue to occur with alarming frequency. Increasing attention to the critical role of patient safety systems and a culture of safety are important. However, the individual professionals and the boards that regulate them are also important. As the patient safety movement has evolved so has our state medical board's response to wrong site, side and patient surgeries. Between 1998 and 2008 the Rhode Island Board of Medical Licensure and Discipline investigated reports of 10 wrong side, site and patient surgeries or procedures. Four were neurosurgeries, two orthopedic and one each gynecologic, ENT, ophthalmologic and vascular.

scholarly journals Wrong-Site Surgery in Pennsylvania During 2015–2019: A Study of Variables Associated With 368 Events From 178 Facilities

2020 ◽  
pp. 24-39
Author(s):  
Robert Yonash ◽  
Matthew Taylor
Keyword(s):  
Patient Safety ◽  
Body Part ◽  
Body Region ◽  
Error Type ◽  
Near Misses ◽  
Healthcare Facilities ◽  
Safety Reporting ◽  
Wrong Site Surgery ◽  
Wrong Side ◽  
Wrong Site

Wrong-site surgery (WSS) is a well-known type of medical error that may cause a high degree of patient harm. In Pennsylvania, healthcare facilities are mandated to report WSS events, among other patient safety concerns, to the Pennsylvania Patient Safety Reporting System (PA-PSRS) database. In the study we identified instances of WSS events (not including near misses) that occurred during 2015–2019 and were reported to PA-PSRS. During the five-year period, we found that 178 healthcare facilities reported a total of 368 WSS events, which was an average of 1.42 WSS events per week in Pennsylvania. Also, we revealed that 76% (278 of 368) of the WSS events contributed to or resulted in temporary harm or permanent harm to the patient. Overall, the study shows that the frequency of WSS varied according to a range of variables, including error type (e.g., wrong side, wrong site, wrong procedure, wrong patient); year; facility type; hospital bed size; hospital procedure location; procedure; body region; body part; and clinician specialty. Our findings are aligned with some of the previous research on WSS; however, the current study also addresses many gaps in the literature. We encourage readers to use the visuals in the manuscript and appendices to gain new insight into the relation among the variables associated with WSS. Ultimately, the findings reported in the current study help to convey a more complete account of the variables associated with WSS, which can be used to assist staff in making informed decisions about allocating resources to mitigate risk.

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