Never events in orthopaedics: A nationwide data analysis and guidance on preventative measures

2021 ◽  
pp. 1-14
Author(s):  
Ahmed T. Hafez ◽  
Islam Omar ◽  
Balaji Purushothaman ◽  
Yusuf Michla ◽  
Kamal Mahawar
Keyword(s):  
Orthopaedic Surgery ◽  
Knee Prosthesis ◽  
Intraoperative Imaging ◽  
Quality Of Healthcare ◽  
Joint Registry ◽  
Retained Foreign Body ◽  
Preventative Measures ◽  
Implant Selection ◽  
Never Events

BACKGROUND: Never Events (NE) are serious clinical incidents that are wholly preventable if appropriate institutional safeguards are in place and followed. They are often used as a surrogate of the quality of healthcare delivered by an institution. Most NEs are surgical and orthopaedic surgery is one of the most involved specialties. OBJECTIVE: The aim of this study was to identify common NE themes associated with orthopaedics within the National Health Service (NHS) of England. METHOD: We conducted an observational study analysing the annual NE data published by the NHS England from 2012 to 2020 to collate all orthopaedic surgery-related NE and construct relevant recurring themes. RESULTS: We identified 460 orthopaedic NE out of a total of 3247 (14.16%) reported NE to NHS England. There were 206 Wrong implants/prostheses under 8 different themes. Wrong hip and knee prosthesis were the commonest “wrong implants” (n = 94; 45.63% and n = 91; 44.17% respectively). There were 197 “Wrong-site surgery” incidents in 22 different themes. The commonest of these was the laterality problems accounting for 64 (32.48%) incidents followed by 63 (31.97%) incidents of wrong spinal level interventions. There were 18 (9.13%) incidents of intervention on the wrong patients and 17 (8.62%) wrong incisions. Retained pieces of instruments were the commonest retained foreign body with 15 (26.13%) incidents. The next categories were retained drill parts and retained instruments with 13 (22.80%) incidents each. CONCLUSION: We identified 47 different themes of NE specific to orthopaedic surgery. Awareness of these themes would help in their prevention. Site marking can be challenging in the presence of cast and on operating on the digits and spine. Addition of a Real-time intra-operative implant scan to the National Joint Registry can avoid wrong implant selection while Fiducial markers, intraoperative imaging, O-arm navigation, and second time-out could help prevent wrong level spinal surgery.

QUALITY MANAGEMENT PRINCIPLES OF CLINICAL AND LABORATORY ACTIVITIES

2018 ◽  
Vol 28 (2) ◽  
pp. 689-693
Author(s):  
Nikola Sabev
Keyword(s):  
Evaluation System ◽  
Quality Of Healthcare ◽  
Laboratory Analysis ◽  
Medical Services ◽  
Administrative Authority ◽  
Specific Level ◽  
Goods And Services ◽  
Laboratory Activities ◽  
Analytical Accuracy

Providing a specific level of healthcare quality is an important and a complex issue, determined by the extent of influence of number of interrelated and predetermined factors that act at different stages throughout the continuum of healthcare activities. A final healthcare product is a complex conglomerate of goods and services being heterogeneous with a time-varying result and a pronounced individuality. Thus, healthcare managers are required to put its supporting and continuous upgrading at the core of their efforts, which in turn will result in cost reduction, good collaboration between individual professionals, improved financial performance and, ultimately, patients will be optimally serviced and their needs and expectations will be satisfied.Indicators to measure quality of medical services give an idea of their characteristics, conditions and requirements for implementation. In this respect, quality assurance in clinical laboratories is an important process involving a complex system of planned actions at all stages of laboratory analysis in order to achieve the most accurate results with the aim of achieving the most accurate result, of monitoring the effect of the treatment and prognosis of the disease in question. The high quality of laboratory medical services helps modern clinicians in their practical activities and is a guarantor of achieving an adequate healthcare outcome. The ‘Quality in Laboratory Medicine’ concept evolves over time, focusing not only on analytical accuracy but also on a broader and more comprehensive basis that takes into account all the steps of clinical and laboratory analysis, providing valuable information in the process of making clinical decisions that are subordinated entirely to the cares of the patient.All healthcare professionals under the administrative authority of the medical institution, that should guarantee the necessary resources for this process, should participate in providing and improving the quality of services. It is necessary to cover the entire organizational structure, by paying attention to the optimization of the relations between staff and patients. Healthcare managers should provide permanent monitoring and a process evaluation system at each stage, allowing options for choosing alternatives for a solution and precise selectivity, aimed at improving the quality of healthcare, in particular, clinical and laboratory activities and services.

scholarly journals Systematic Analysis of Literature on the Marketing of Healthcare Systems. Challenges for Russian and Romanian Healthcare Systems

Healthcare ◽  
2021 ◽  
Vol 9 (6) ◽  
pp. 656
Author(s):  
Vladimir Bulatnikov ◽  
Cristinel Petrişor Constantin
Keyword(s):  
Quality Of Healthcare ◽  
Healthcare Systems ◽  
Business Environment ◽  
Competitive Advantages ◽  
Systematic Analysis ◽  
Scientific Databases ◽  
Advantages And Disadvantages ◽  
Funds Allocation ◽  
New Perspective

This paper aims at finding the most dominant ideas about the marketing of healthcare systems highlighted in the mainstream literature, with a focus on Russia and Romania. To reach this goal, a systematic analysis of literature was conducted and various competitive advantages and disadvantages of the medical models that require special attention from the governments are considered. In this respect we examined 106 papers published during 2006 to 2020 found on four scientific databases. They were selected using inclusion and exclusion criteria according to PRISMA methodology. The main findings of the research consist of the opportunity to use marketing tools in order to improve the quality of healthcare systems in the named countries. Thus, using market orientation, the managers of healthcare systems could stimulate the innovation, the efficiency of funds allocation and the quality of medical services. The results will lead to a better quality of population life and to an increasing of life expectancy. As this paper reviews some articles from Russian literature, it can add a new perspective to the topic. These outcomes have implications for government, business environment, and academia, which should cooperate in order to develop the healthcare system using marketing strategies.

Estimates of the effects of centralization policy for surgery in Japan: does centralization affect the quality of healthcare for esophagectomies?

Surgery Today ◽  
2021 ◽  
Author(s):  
Arata Takahashi ◽  
Hiroyuki Yamamoto ◽  
Yoshihiro Kakeji ◽  
Shigeru Marubashi ◽  
Mitsukazu Gotoh ◽  
...  
Keyword(s):  
Quality Of Healthcare

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.

Quality of healthcare information on the Internet: the case of Apicectomies

Oral Surgery ◽  
2017 ◽  
Vol 10 (4) ◽  
pp. e35-e39 ◽  
Author(s):  
M. Parvizi ◽  
N.N. Talai ◽  
Z. Parvizi
Keyword(s):  
Quality Of Healthcare ◽  
The Internet ◽  
Healthcare Information

scholarly journals Association of patients’ perception of quality of healthcare received and colorectal cancer screening uptake: An analysis of two national surveys in the United States

2020 ◽  
Author(s):  
Karan Chawla ◽  
Angesom Kibreab ◽  
Victor & Scott ◽  
Edward L. Lee ◽  
Farshad Aduli ◽  
...  
Keyword(s):  
Colorectal Cancer ◽  
United States ◽  
Healthcare Delivery ◽  
Quality Of Healthcare ◽  
Healthcare Services ◽  
The United States ◽  
Crc Screening ◽  
Fair Poor ◽  
National Trends

Objective: It is unknown whether patients’ ratings of the quality of healthcare services they receive truly correlate with the quality of care from their providers. Understanding this association can potentiate improvement in healthcare delivery. We evaluated the association between patients’ ratings of the quality of healthcare services received and uptake of colorectal cancer (CRC) screening. Subject and Methods: We used two iterations of the Health Information National Trends Survey (HINTS) of adults in the United States. HINTS 2007 (4,007 respondents; weighted population=75,397,128) evaluated whether respondents were up-to-date with CRC screening while HINTS 4 cycle 3 (1,562 respondents; weighted population=76,628,000) evaluated whether participants had ever received CRC screening in the past. All included respondents from both surveys were at least 50 years of age, had no history of CRC, and had rated the quality of healthcare services that they had received at their healthcare provider’s office in the previous 12 months. Results: HINTS 2007 data showed that respondents who rated their healthcare as good, or fair/poor were significantly less likely to be up to date with CRC screening compared to those who rated their healthcare as excellent. We found comparable results from analysis of HINTS 4 cycle 3 data with poorer uptake of CRC screening as the healthcare quality ratings of respondents’ reduced. Conclusion: Our study suggested that patients who reported receiving lower quality of healthcare services were less likely to have undergone and be compliant with CRC screening recommendations. It is important to pay close attention to patient feedback surveys in order to improve healthcare delivery.

MEASURING SPATIAL HEALTHCARE FACILITIES ACCESSIBILITY USING TWO-STEP FLOATING CATCHMENT ANALYSIS (2SFCA) (Case Study: Cianjur Regency, Indonesia)

2021 ◽  
pp. 11
Author(s):  
Muhamad Iqbal Januadi Putra ◽  
Nabila Dety Novia Utami
Keyword(s):  
Travel Time ◽  
Quality Of Healthcare ◽  
Healthcare Services ◽  
Spatial Accessibility ◽  
Healthcare Facilities ◽  
Spatial Disparities ◽  
Time Threshold

The presence of healthcare facilities is quite essential to provide good healthcare services in a particular area, however, the existence of healthcare facilities is not evenly distributed in Cianjur Regency. This condition leads to the disparities of healthcare facilities across the Cianjur Regency. In this paper, we aim to measure and map the spatial disparities of healthcare facilities using a Two-Step Floating Catchment Analysis (2SFCA). This method can calculate the magnitude of spatial accessibility for healthcare facilities by formulating the travel time threshold and the quality of healthcare facilities across the study area. This research shows the result that the spatial accessibility of healthcare facilities in the Cianjur Regency is not evenly distributed across the districts. The spatial accessibility value resulted from 2SFCA is ranging from 0- 3.97. A low value indicates low spatial accessibility, while a higher value shows good accessibility. The majority of districts in the Cianjur Regency have the spatial accessibility value 0-0.5 (86%). Meanwhile, only a few have the higher value; value 0.5-0.99 as much as 6.6%, 0.99-1.49 as 3.3%, and 3.48-3.97 has a percentage of 3.3%. Also, this analysis results in the cluster of good spatial accessibility in healthcare facilities, namely the Pagelaran District and Cipanas District. Interestingly, the downtown of Cianjur Regency has lower spatial accessibility compared to both areas.

Sign in / Sign up

Export Citation Format

Share Document