Common preventable errors in hand surgery: Analysis of NHS never events data and a proposed safety checklist

Abstract

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.

Urology never events in the United Kingdom: A retrospective 10‐year review

“…Precautionary principals have been made available including the WHO ‘Safe Surgery Checklist’ that aim to facilitate safe operative practices and prevent wrong site surgery and retained foreign bodies. However, a number of studies have demonstrated that NEs continue to occur 4,8,9 . Practices such as utilising radiopaque markers to indicate surgical side, for example, an ECG lead sticker, rather than relying on pen markings that are frequently covered by sterile drapes, may reduce the incidence of wrong site surgery 6 .…”

“…However, a number of studies have demonstrated that NEs continue to occur. 4 , 8 , 9 Practices such as utilising radiopaque markers to indicate surgical side, for example, an ECG lead sticker, rather than relying on pen markings that are frequently covered by sterile drapes, may reduce the incidence of wrong site surgery. 6 Coloured markers on the distal portion of ureteric stents could be introduced to indicate ‘left’ and ‘right’ to help prevent removal stents from the wrong side.…”

“…This is despite the potential of NEs to cause major patient harm; indeed, NEs result in death in up to 20% of cases 8 . Furthermore, £74.5million was paid by the NHS over a 20‐year period as a result of litigation claims relating to urology 9 …”

“… 8 Furthermore, £74.5million was paid by the NHS over a 20‐year period as a result of litigation claims relating to urology. 9 …”

“…8 Furthermore, £74.5million was paid by the NHS over a 20-year period as a result of litigation claims relating to urology. 9 The aim of this study was to assess the prevalence of NEs specific to urology in the United Kingdom and to identify relevant themes that may help to mitigate their occurrence in future.…”