Never events in orthopaedics: A nationwide data analysis and guidance on preventative measures

Hafez, Ahmed; Omar, Islam; Purushothaman, Balaji; Michla, Yusuf; Mahawar, Kamal

doi:10.3233/jrs-210051

Cited by 4 publications

(5 citation statements)

References 23 publications

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“…We excluded another 337 articles after reviewing the full-text citations largely because they neither identified individual NEs nor specified an existing framework (47%), or because they were non-scholarly (eg, media releases; 30%). Thus, our analyses were based on 367 articles 3 4 7–11 18–377. A full list of these articles and the information we extracted from them are found in online supplemental tables 1 and 2.…”

Section: Resultsmentioning

confidence: 99%

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

et al. 2023

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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.

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Section: Resultsmentioning

confidence: 99%

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

et al. 2023

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“…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 .…”

Section: Discussionmentioning

confidence: 99%

“…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.…”

Section: Discussionmentioning

confidence: 99%

“…To date, no publications have addressed the burden of NEs in urology in the United Kingdom or internationally. 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 …”

Section: Introductionmentioning

confidence: 99%

“…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 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.…”

mentioning

confidence: 99%

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

Loyala,

Ang,

Down

et al. 2024

BJUI Compass

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ObjectivesThe aim was to assess the prevalence of never events (NEs) specific to urology in the United Kingdom and identify commonly occurring themes.MethodsData from the National Health Service (NHS) NEs website were obtained and all NEs from 2012 to 2022 were reviewed. Urology‐specific NEs were identified and further analysed in their respective categories. Data regarding the total number of surgical procedures performed in the NHS specific to each specialty were obtained via the NHS Hospital Episode Statistics website.ResultsThere were 3972 NEs recorded over the 10‐year period with 95 (2.4%) of these as a result of urology surgery. The most common surgical intervention associated with a urological NE was ureteric stenting, which comprised 45/95 (47.4%) of all analysed NEs. These consisted of wrong site ureteric stent insertion (n = 29), wrong site ureteric stent removal (n = 9), wrong stent type (n = 5) and retained guidewires (n = 2). There were 7.14 million urology surgeries performed in the 10‐year period, and prevalence was 0.0013%.ConclusionNEs are fully preventable serious incidents in the NHS. This is the first study to investigate the prevalence of NEs in urology in the United Kingdom. This study demonstrates that in the last 10 years the prevalence of urology NEs is low at 0.0013%, with ureteric stent procedures accounting for more than half of the NEs. Urologists should be mindful of the potential for wrong site surgery in urologic stenting procedures.

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

Hafez

Omar²,

Ang

et al. 2023

JRS

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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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Never events in orthopaedics: A nationwide data analysis and guidance on preventative measures

Cited by 4 publications

References 23 publications

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

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

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

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

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