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

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.

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Preventable Errors in the Operating Room—Part 2: Retained Foreign Objects, Sharps Injuries, and Wrong Site Surgery

Current Problems in Surgery ◽

10.1067/j.cpsurg.2007.04.002 ◽

2007 ◽

Vol 44 (6) ◽

pp. 352-381 ◽

Cited By ~ 20

Author(s):

T. Forcht Dagi ◽

Ramon Berguer ◽

Stephen Moore ◽

H. David Reines

Keyword(s):

Operating Room ◽

Wrong Site Surgery ◽

Foreign Objects ◽

Sharps Injuries ◽

Wrong Site

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Operating Room Briefings and Wrong-Site Surgery

Journal of the American College of Surgeons ◽

10.1016/j.jamcollsurg.2006.10.018 ◽

2007 ◽

Vol 204 (2) ◽

pp. 236-243 ◽

Cited By ~ 147

Author(s):

Martin A. Makary ◽

Arnab Mukherjee ◽

J. Bryan Sexton ◽

Dora Syin ◽

Emmanuelle Goodrich ◽

...

Keyword(s):

Operating Room ◽

Wrong Site Surgery ◽

Wrong Site

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The use of collaboration to implement evidence-based safe practices

Journal of Public Health Research ◽

10.4081/jphr.2013.e26 ◽

2013 ◽

Vol 2 (3) ◽

pp. 26 ◽

Cited By ~ 1

Author(s):

John R. Clarke

Keyword(s):

Patient Safety ◽

Best Practices ◽

Operating Room ◽

Medical Error ◽

Near Miss ◽

Evidence Based ◽

Wrong Site Surgery ◽

Eastern Pennsylvania ◽

One Year ◽

Wrong Site

The Pennsylvania Patient Safety Authority receives over 235,000 reports of medical error per year. Near miss and serious event reports of common and interesting problems are analysed to identify best practices for preventing harmful errors. Dissemination of this evidence-based information in the peer-reviewed Pennsylvania Patient Safety Advisory and presentations to medical staffs are not sufficient for adoption of best practices. Adoption of best practices has required working with institutions to identify local barriers to and incentives for adopting best practices and redesigning the delivery system to make desired behaviour easy and undesirable behaviour more difficult. Collaborations, where institutions can learn from the experiences of others, have show decreases in harmful events. The Pennsylvania Program to Prevent Wrong-Site Surgery is used as an example. Two collaborations to prevent wrong-site surgery have been completed, one with 30 institutions in eastern Pennsylvania and one with 19 in western Pennsylvania. The first collaboration achieved a 73% decrease in the rolling average of wrong-site events over 18 months. The second collaboration experienced no wrong-site operating room procedures over more than one year.

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Making the Operating Theatre a 'High-Reliability' Environment

Bulletin of The Royal College of Surgeons of England ◽

10.1308/147363512x13311314195574 ◽

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.

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

British Journal of Surgery ◽

10.1093/bjs/znab309.003 ◽

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.

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Is team-based perception of safety in the operating room associated with self-reported wrong-site surgery? An exploratory cross-sectional survey among physicians

Health Science Reports ◽

10.1002/hsr2.42 ◽

2018 ◽

Vol 1 (6) ◽

pp. e42 ◽

Cited By ~ 1

Author(s):

Stéphane Cullati ◽

Delphine S. Courvoisier ◽

Patricia Francis ◽

Adriana Degiorgi ◽

Paula Bezzola ◽

...

Keyword(s):

Operating Room ◽

Cross Sectional Survey ◽

Cross Sectional ◽

Wrong Site Surgery ◽

Perception Of Safety ◽

Wrong Site

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

British Journal of Surgery ◽

10.1093/bjs/znab361.141 ◽

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.

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