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World Journal of Surgery

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01-03-2021 | Original Scientific Report

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

Authors: Islam Omar, Yitka Graham, Rishi Singhal, Michael Wilson, Brijesh Madhok, Kamal K. Mahawar

Published in: World Journal of Surgery | Issue 3/2021

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.

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Title: Identification of Common Themes from Never Events Data Published by NHS England
Authors: Islam Omar
Yitka Graham
Rishi Singhal
Michael Wilson
Brijesh Madhok
Kamal K. Mahawar
Publication date: 01-03-2021
Publisher: Springer International Publishing
Published in: World Journal of Surgery / Issue 3/2021
Print ISSN: 0364-2313
Electronic ISSN: 1432-2323
DOI: https://doi.org/10.1007/s00268-020-05867-7

At a glance: The STEP trials

Springer Medicine

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

Abstract

Background

Methods

Results

Conclusion

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

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