Repeated never events in plastic surgery: Can human factors help us understand why we fail?

Berner, Juan Enrique; Gokani, Vimal J.; Savage, Jessica Anne; Blackburn, Adam

doi:10.1016/j.bjps.2019.05.048

Cited by 6 publications

(5 citation statements)

References 5 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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“…It may be because the checklists can be difficult to implement effectively [13]. It may also be because of a lack of awareness of specific pitfalls that then repeat themselves [14]. Identification of predisposing factors for each specific NE is beyond the purview of this paper as we have focussed on the identification of themes rather than their prevention in this paper.…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2020

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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.

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“…years. From a human factors perspective, mobile computing devices offer expedited communication channels, which can be particularly useful in time-sensitive scenarios 4 . Our practice will likely continue to change as artificial intelligence applications become widely available 5 .…”

Section: It Is Undeniable How Information Technologies Have Changed M...mentioning

confidence: 99%

“…From a human factors perspective, mobile computing devices offer expedited communication channels, which can be particularly useful in time-sensitive scenarios. 4 Our practice will likely continue to change as artificial intelligence applications become widely available. 5 Our QR code presents a smooth interface to access relevant information from the patient's bedside, which could also serve as a point of entry to other clinical platforms.…”

Section: Dear Sirmentioning

confidence: 99%

Here's My QR, So Call Me Maybe: Facilitating Communication in Free Flap Monitoring Using QR Code Printed Dressing

Chang

Jones

Pafitanis

et al. 2023

J Reconstr Microsurg

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Repeated never events in plastic surgery: Can human factors help us understand why we fail?

Cited by 6 publications

References 5 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

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

Here's My QR, So Call Me Maybe: Facilitating Communication in Free Flap Monitoring Using QR Code Printed Dressing

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