Identification of Common Themes from Never Events Data Published by NHS England

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.

Safety considerations in laparoscopic surgery: A narrative review

“…Another potentially serious issue could be surgery without the knowledge that the patient is pregnant. Though this has implications for all pregnant women and the unborn baby, the implications are even more severe after operations such as bariatric and metabolic surgery[ 11 ]. All women in the childbearing age group should, therefore, be offered a routine urine pregnancy test at preassessment to rule out pregnancy[ 12 ].…”

“…These sessions provide an opportunity for discussion of any anticipated difficulties, measures for prophylaxis of venous thromboembolism, antibiotic prophylaxis, glycaemic control, patient allergies, patient warming, patient positioning, location of the screen, need for X-ray, etc. We strongly recommend team briefings are done as part of the World Health Organisation (WHO) “safe-surgery” checklist, which has been shown to reduce human error and adverse effects while improving communication and teamwork[ 11 , 24 ]. While discussing allergies, particular attention should be paid to allergies to something that would normally be used during or after surgery.…”

“…Regardless of these preferences, basic principles of positioning remain the same. The patient must be secured with a strap over the chest/thighs with or without footrests (depending on whether reverse Trendelenburg position is anticipated during the surgery) to avoid lateral and caudal slippage[ 11 ]. Likewise, for pelvic surgery, the patient may need to be in Trendelenburg position.…”

“…Surgeons should also bear in mind that a curved needle will not go through a 5 mm port whereas a ski-shaped needle will. Curved needles can be lost intra-abdominally in an attempt to retrieve them through a 5 mm port[ 11 ]. Surgeons should always follow any needle during insertion and removal from the abdominal cavity.…”

“…Surgeons should finally check the operating count with nurses and do a proper "time out" to ensure all planned procedures have been performed. The operating count should include surgical specimens and specimen retrieval bags as it is not uncommon during laparoscopic surgery for surgeons to leave a specimen/retrieval bag intraabdominally during the surgery for later removal[ 11 ]. At the end of the procedure, we recommend a mental pause for the surgeon to reflect on the procedure – especially consider if all planned procedures have been performed; all foreign bodies such as tonsil swabs, retrieval bags, removed previously placed foreign bodies such as gastric bands, and specimens have been removed; and all ports that needed closing have been closed.…”