Identification of Common Themes from Never Events Data Published by NHS England
- PDF / 274,775 Bytes
- 8 Pages / 595.276 x 790.866 pts Page_size
- 106 Downloads / 146 Views
ORIGINAL SCIENTIFIC REPORT
Identification of Common Themes from Never Events Data Published by NHS England Islam Omar1 • Yitka Graham1,2 • Rishi Singhal3 • Michael Wilson4 • Brijesh Madhok5 Kamal K. Mahawar1,2
•
Accepted: 31 October 2020 Ó Socie´te´ Internationale de Chirurgie 2020
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 (laterality) 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.
& Kamal K. Mahawar [email protected] 1
Bariatric Unit, Department of General Surgery, Sunderland Royal Hospital, South Tyneside and Sunderland NHS Trust, Sunderland SR4 7TP, UK
2
Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland SR1 3SD, UK
3
Consultant Bariatric & Upper GI Surgeon, Birmingham Heartlands Hospital, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
4
Consultant Upper GI Surgeon, NHS Forth Valley, Larbert, Scotland, UK
5
Royal Derby Hospital, University Hospitals of Derby & Burton NHS Foundation Trust, Derby, UK
123
World J Surg
Abbreviations NE Never Event(s) IOM Institute of Medicine USA United States of America UK United Kingdom NHS National Health Service NPSA National Patient Safety Agency WHO World Health Organisation NRLS National Reporting and Learning System STEIS Strategic Executive Information System NatSSIPs National Safety Standards for Invasive Procedures LocSSIPs Local Safety Sta
Data Loading...
