Identifying a list of healthcare ‘never events’ to effect system change: a systematic review and narrative synthesis

Abstract

BackgroundNever events (NEs) are patient safety incidents that are preventable and so serious they should never happen. To reduce NEs, several frameworks have been introduced over the past two decades; however, NEs and their harms continue to occur. These frameworks have varying events, terminology and preventability, which hinders collaboration. This systematic review aims to identify the most serious and preventable events for targeted improvement efforts by answering the following questions: Which patient safety events are most frequently classified as never events? Which ones are most commonly described as entirely preventable?MethodsFor this narrative synthesis systematic review we searched Medline, Embase, PsycINFO, Cochrane Central and CINAHL for articles published from 1 January 2001 to 27 October 2021. We included papers of any study design or article type (excluding press releases/announcements) that listed NEs or an existing NE framework.ResultsOur analyses included 367 reports identifying 125 unique NEs. Those most frequently reported were surgery on the wrong body part, wrong surgical procedure, unintentionally retained foreign objects and surgery on the wrong patient. Researchers classified 19.4% of NEs as ‘wholly preventable’. Those most included in this category were surgery on the wrong body part or patient, wrong surgical procedure, improper administration of a potassium-containing solution and wrong-route administration of medication (excluding chemotherapy).ConclusionsTo improve collaboration and facilitate learning from errors, we need a single list that focuses on the most preventable and serious NEs. Our review shows that surgery on the wrong body part or patient, or the wrong surgical procedure best meet these criteria.

Grading recommendations for enhanced patient safety in sentinel event analysis: the recommendation improvement matrix

“…Really improving patient safety on the basis of these analysis has been proven challenging. 1 The frequency of SEs, which are incidents that lead to death or serious harm to patients, has essentially remained unchanged in recent years. 1 2 Improving patient safety after an SE is based on a learning cycle.…”

Challenges of safety culture in Surgical Center: mixed methods study

“…So-called near misses or almost errors were less frequent in SC than in other units, such as hospitalization, intensive care and pediatrics ( 10 ) . On the other hand, the occurrence of adverse events of very high severity — known as never events — is alarming when it comes to the intraoperative and immediate post-operative period, such as surgery in the wrong laterality, wrong procedure and/or patient, retention of material inside the patient and electrocautery burns ( 11 ) . Added to this is the fact that up to 90% of adverse events related to surgery are classified as preventable ( 12 ) , making it imperative that patient safety measures in the SC are instituted and encouraged, which can be accomplished with greater assertiveness through systematic analyzes of safety attitudes in these environments.…”

“…Los llamados near misses o casi errores ya fueron menos frecuentes en los CQ que en otras unidades, como hospitalización, cuidados intensivos y pediatría ( 10 ) . Por otro lado, resulta alarmante la aparición de eventos adversos de muy alta gravedad – conocidos como never events –, en el intraoperatorio y postoperatorio inmediato, como cirugía en lateralidad incorrecta, procedimiento y/o paciente incorrectos, retención de material en el paciente y quemaduras por electrocauterización ( 11 ) . A esto se suma el hecho de que hasta el 90% de los eventos adversos relacionados con la cirugía se clasifican como prevenibles ( 12 ) , por lo que es imperativo instituir y fomentar medidas de seguridad del paciente en el CQ, lo que se puede lograr con mayor asertividad por medio de análisis sistemáticos de las actitudes de seguridad en esos entornos.…”

“…Os chamados near misses ou quase erros já foram menos frequentes nos CC do que em outras unidades, como na internação, terapia intensiva e pediatria ( 10 ) . Em contrapartida, a ocorrência de eventos adversos de altíssima severidade — conhecidos como never events — é alarmante quando trata-se do período intraoperatório e pós-operatório imediato, como cirurgia em lateralidade errada, procedimento e/ou paciente errado, retenção de material no paciente e queimadura por eletrocautério ( 11 ) . Soma-se a isso o fato de que até 90% dos eventos adversos relacionados com o ato cirúrgico são classificados como preveníveis ( 12 ) , tornando imperativo que as medidas de segurança do paciente no CC sejam instituídas e estimuladas, o que pode ser realizado com maior assertividade por meio de análises sistemáticas das atitudes de segurança nesses ambientes.…”