Common general surgical never events: analysis of NHS England never event data

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

Objectives

The aim was to assess the prevalence of never events (NEs) specific to urology in the United Kingdom and identify commonly occurring themes.

Methods

Data 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.

Results

There 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%.

Conclusion

NEs 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.

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

BACKGROUND

Never 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?

METHODS

For 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.

RESULTS

Our 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).

CONCLUSIONS

To 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.

AVOIDable medical errors in invasive procedures: Facts on the ground - An NHS staff survey

BACKGROUND

Never Events represent a serious problem with a high burden on healthcare providers' facilities. Despite introducing various safety checklists and precautions, many Never Events are reported yearly.

OBJECTIVE

This survey aims to assess awareness and compliance with the safety standards and obtain recommendations from the National Health Service (NHS) staff on preventative measures.

METHODS

An online survey of 45 questions has been conducted directed at NHS staff involved in invasive procedures. The questions were designed to assess the level of awareness, training and education delivered to the staff on patient safety. Moreover, we designed a set of focused questions to assess compliance with the National Safety Standards for Invasive Procedures (NatSSIPs) guidance. Open questions were added to encourage the staff to give practical recommendations on tackling and preventing these incidents. Invitations were sent through social media, and the survey was kept live from 20/11/2021 to 23/04/2022.

RESULTS

Out of 700 invitations sent, 75 completed the survey (10.7%). 96% and 94.67% were familiar with the terms Never Events and near-miss, respectively. However, 52% and 36.49% were aware of National and Local Safety Standards for Invasive procedures (NatSSIPs-LocSSIPs), respectively. 28 (37.33%) had training on preventing medical errors. 48 (64%) believe that training on safety checklists should be delivered during undergraduate education. Fourteen (18.67%) had experiences when the checklists failed to prevent medical errors. 53 (70.67%) have seen the operating list or the consent forms containing abbreviations. Thirty-three (44%) have a failed counting reconciliation algorithm. NHS staff emphasised the importance of multi-level checks, utilisation of specific checklists, patient involvement in the safety checks, adequate staffing, avoidance of staff change in the middle of a procedure and change of list order, and investment in training and education on patient safety.

CONCLUSION

This survey showed a low awareness of some of the principal patient safety aspects and poor compliance with NatSSIPs recommendations. Checklists fail on some occasions to prevent medical errors. Process redesign creating a safe environment, and enhancing a safety culture could be the key. The study presented the recommendations of the staff on preventative measures.

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

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.

Deep Learning-Based System for Preoperative Safety Management in Cataract Surgery

An artificial intelligence-based system was implemented for preoperative safety management in cataract surgery, including facial recognition, laterality (right and left eye) confirmation, and intraocular lens (IOL) parameter verification. A deep-learning model was constructed with a face identification development kit for facial recognition, the You Only Look Once Version 3 (YOLOv3) algorithm for laterality confirmation, and the Visual Geometry Group-16 (VGG-16) for IOL parameter verification. In 171 patients who were undergoing phacoemulsification and IOL implantation, a mobile device (iPad mini, Apple Inc.) camera was used to capture patients’ faces, location of surgical drape aperture, and IOL parameter descriptions on the packages, which were then checked with the information stored in the referral database. The authentication rates on the first attempt and after repeated attempts were 92.0% and 96.3% for facial recognition, 82.5% and 98.2% for laterality confirmation, and 67.4% and 88.9% for IOL parameter verification, respectively. After authentication, both the false rejection rate and the false acceptance rate were 0% for all three parameters. An artificial intelligence-based system for preoperative safety management was implemented in real cataract surgery with a passable authentication rate and very high accuracy.

The first international Delphi consensus statement on Laparoscopic Gastrointestinal surgery

BACKGROUND

Laparoscopic surgery has almost replaced open surgery in many areas of Gastro-Intestinal (GI) surgery. There is currently no published expert consensus statement on the principles of laparoscopic GI surgery. This may have affected the training of new surgeons. This exercise aimed to achieve an expert consensus on important principles of laparoscopic GI surgery.

METHODS

A committee of 38 international experts in laparoscopic GI surgery proposed and voted on 149 statements in two rounds following a strict modified Delphi protocol.

RESULTS

A consensus was achieved on 133 statements after two rounds of voting. All experts agreed on tailoring the first port site to the patient, whereas 84.2% advised avoiding the umbilical area for pneumoperitoneum in patients who had a prior midline laparotomy. Moreover, 86.8% agreed on closing all 15 mm ports irrespective of the patient's body mass index. There was a 100% consensus on using cartridges of appropriate height for stapling, checking the doughnuts after using circular staplers, and keeping the vibrating blade of the ultrasonic energy device in view and away from vascular structures. An 84.2% advised avoiding drain insertion through a ≥10 mm port site as it increases the risk of port-site hernia. There was 94.7% consensus on adding laparoscopic retrieval bags to the operating count and ensuring any surgical specimen left inside for later removal is added to the operating count.

CONCLUSION

Thirty-eight experts achieved a consensus on 133 statements concerning various aspects of laparoscopic GI Surgery. Increased awareness of these could facilitate training and improve patient outcomes.