scholarly journals Wrong-Site Procedures: Preventable Never Events that Continue to Happen

2018 ◽  
Author(s):  
Andrew Lin ◽  
Brian Wernick ◽  
Julia C. Tolentino ◽  
Stanislaw P. Stawicki
Keyword(s):  
Never Events ◽  
Wrong Site

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.

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.

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 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.

Expert Advises on Avoiding ‘Never Events’

2009 ◽  
Vol 10 (6) ◽  
pp. 15
Author(s):  
HEIDI SPLETE
Keyword(s):  
Never Events
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