In contrast to aSBP1, the association between bSBP and aSBP2 is significantly less dominant and therefore aSBP2 may have potential prognostic superiority over bSBP.
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.
BACKGROUND: Hand surgical procedures are common interventions in elective and emergency settings. The complex nature of the injuries and management by multiple specialities could be a potential source of medical errors and never events (NEs). Awareness of the common NEs could potentially help prevent their occurrence in the future. OBJECTIVE: To analyse the NHS England database to identify the common NEs in hand surgery and present a simple, practical safety checklist for hand surgery. METHODS: The NHS NEs database from 2012 to 2021 has been analysed to identify the common hand surgery-related never events. We identified the common categories and themes within. Our theme development process is based on anatomical considerations and the nature of the incidents. Additionally, we designed a simple Safety Checklist for hand surgery. RESULTS: We identified a total of 3742 never events with 50 incidents related to hand surgery, representing (1.3%). Wrong-site surgery was the commonest category (n = 30), representing 60% of the hand surgery-related NEs. We identified seven different themes under wrong-site surgery. Wrong finger or digit surgery was the commonest theme, with 17 reported incidents representing 57% of wrong-site surgeries. This is followed by five wrong digits injections and three wrong k wire placements representing 16.6% and 10%, respectively. The second most common category was wrong incisions (n = 15), representing 30%; 13 patients had wrong finger incisions. Two patients had carpal tunnel incisions before surgeons realised that the procedures were for trigger finger release. The third category included four wrong procedures, with two incidents of carpal tunnel release instead of trigger finger operation or Dequervain tendon release. Finally, one patient had an injection for carpal tunnel intended for another patient. CONCLUSION: Hand surgery-related NEs represent a small fraction (1.3%) of all NEs within the NHS database. We identified 50 hand surgery-related NEs arranged into 14 different themes. Additionally, we proposed a hand surgery-specific safety checklist to reduce the incidence of these incidents in the future.
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