1
|
Zaslow J, Fortier J, Garber G. The problem with 'never events'. BMJ Qual Saf 2024:bmjqs-2023-016981. [PMID: 39009431 DOI: 10.1136/bmjqs-2023-016981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2024] [Indexed: 07/17/2024]
Affiliation(s)
- Joanna Zaslow
- Evidence Synthesis Unit, Canadian Medical Protective Association, Ottawa, Ontario, Canada
| | | | - Gary Garber
- Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| |
Collapse
|
2
|
Szymczak J. What's in a name? On the rhetorical harm of 'never events'. BMJ Qual Saf 2024:bmjqs-2024-017395. [PMID: 39009430 DOI: 10.1136/bmjqs-2024-017395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2024] [Indexed: 07/17/2024]
Affiliation(s)
- Julia Szymczak
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| |
Collapse
|
3
|
Yamaguchi A, Tsukimoto S, Kuroda H, Imaizumi U, Katagiri N, Katayama T, Kishimoto N, Kido K, Abe T, Sanuki T. Survey on the Awareness of the Use of Oropharyngeal Throat Packs in Dental Anesthesia: An International Online Survey. Cureus 2024; 16:e52320. [PMID: 38357064 PMCID: PMC10866626 DOI: 10.7759/cureus.52320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2024] [Indexed: 02/16/2024] Open
Abstract
INTRODUCTION Oropharyngeal throat packs (OPTPs) are frequently used to administer general anesthesia during oral surgery and dental procedures. However, the use of OPTPs has remained controversial, with concerns about their effectiveness, the potential for falling short of expectations, and the inherent risk of serious oversight in removing them. This study aimed to assess the awareness of dental anesthesiologists in the United States of America (USA) and Japan regarding the use of OPTPs. METHODS An online questionnaire was distributed to 41 dental anesthesia education facilities in May 2023 and responses were obtained from 32 facilities. RESULTS The responses to the questionnaire indicated that dental anesthesiologists in both the USA and Japan believe that using OPTPs during general anesthesia with airway securement is of significant importance, albeit with varying primary purposes for their application. In contrast, notable disparities were observed between the USA and Japan regarding the perceived importance and routine use of OPTPs during open-airway general anesthesia. In both countries, there is a common understanding that the residual risks of OPTPs are severe and that multiple preventive procedures are required. CONCLUSIONS The present study showed that dental anesthesiologists in the USA and Japan believed that the use of OPTPs was generally necessary for dental anesthesia. However, there was a difference in awareness between Japan and the USA regarding the importance of OPTPs for open-airway general anesthesia. Therefore, there should be a consensus among dental anesthesiologists in Japan and the USA on using OPTPs during open-airway general anesthesia in the near future.
Collapse
Affiliation(s)
- Atsuki Yamaguchi
- Department of Dental Anesthesiology, Kanagawa Dental University, Yokosuka, JPN
| | - Shota Tsukimoto
- Department of Dental Anesthesiology, Kanagawa Dental University, Yokosuka, JPN
| | - Hidetaka Kuroda
- Department of Dental Anesthesiology, Kanagawa Dental University, Yokosuka, JPN
| | - Uno Imaizumi
- Department of Dental Anesthesiology, Kanagawa Dental University, Yokosuka, JPN
| | - Norika Katagiri
- Department of Dental Anesthesiology, Kanagawa Dental University, Yokosuka, JPN
| | - Tomomi Katayama
- Department of Dental Anesthesiology, Kanagawa Dental University, Yokosuka, JPN
| | - Naotaka Kishimoto
- Department of Dental Anesthesiology, Dentistry and Graduate School of Medical and Dental Sciences, Niigata University, Niigata, JPN
| | - Kanta Kido
- Department of Dental Anesthesiology, Hokkaido University, Sapporo, JPN
- Department of Dental Anesthesiology, Kanagawa Dental University, Yokosuka, JPN
| | - Takahiro Abe
- Department of Oral and Maxillofacial Surgery, Kanagawa Dental University, Yokosuka, JPN
| | - Takuro Sanuki
- Department of Dental Anesthesiology, Kanagawa Dental University, Yokosuka, JPN
| |
Collapse
|
4
|
Schwappach D, Havranek MM. Are temporal trends in retained foreign object rates after surgery in Switzerland impacted by increasing coding intensity? A retrospective analysis of hospital routine data from 2000 to 2019. BMJ Open 2023; 13:e075660. [PMID: 37562932 PMCID: PMC10423772 DOI: 10.1136/bmjopen-2023-075660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/26/2023] [Indexed: 08/12/2023] Open
Abstract
OBJECTIVES Retained foreign objects (RFOs) after surgery can cause harm to patients and negatively impact clinician and hospital reputation. RFO incidence based on administrative data is used as a metric of patient safety. However, it is unknown how differences in coding intensity across hospitals and years impact the number of reported RFO cases. The objective of this study is to investigate the temporal trend of RFO incidence at a national level and the impact of changes in coding practices across hospitals and years. DESIGN Retrospective study using administrative hospital data. SETTING AND PARTICIPANTS 21 805 005 hospitalisations at 354 Swiss acute-care hospital sites PRIMARY AND SECONDARY OUTCOME MEASURES: RFO incidence over time, the distribution of RFOs across hospitals and the impact of differences in coding intensity across the hospitals and years. RESULTS The annual RFO rate more than doubled between 2000 and 2019 (from 4.6 to 11.8 with a peak of 17.0 in 2014) and coincided with increasing coding intensity (mean number of diagnoses: 3.4, SD 2.0 in 2000; 7.40, SD 5.2 in 2019). After adjusting for patient characteristics, two regression models confirmed that coding intensity was a significant predictor of both whether RFO cases were reported at the hospital level (OR: 12.94; 95% CI: 7.38 to 22.68) and the number of reported cases throughout the period at the national level (Incidence Rate Ratio (IRR): 5.95; 95% CI: 1.11 to 31.82). CONCLUSIONS Our results raise concerns about the use of RFO incidence for comparing hospitals, countries and years. Utilising coding indices could be employed to mitigate the effects of coding intensity on RFO rates.
Collapse
Affiliation(s)
- David Schwappach
- Faculty of Health Sciences and Medicine, University of Lucerne, Luzern, Switzerland
| | - Michael M Havranek
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| |
Collapse
|
5
|
Schwappach D, Pfeiffer Y. Root causes and preventability of unintentionally retained foreign objects after surgery: a national expert survey from Switzerland. Patient Saf Surg 2023; 17:15. [PMID: 37296424 DOI: 10.1186/s13037-023-00366-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 05/31/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Retained foreign objects (RFO) after surgery are rare, serious patient safety events. In international comparisons based on routine data, Switzerland had remarkably high RFO rates. The objectives of this study were to 1) explore national key stakeholders' views on RFO as a safety problem, its preventability and need for action in Switzerland; and 2) to assess their interpretation of Switzerland's RFO incidence compared to other countries. METHODS A semi-structured expert survey was conducted among national key representatives, including clinician experts, patient advocates, health administration representatives and other relevant stakeholders (n = 21). Data were coded and analyzed to generate themes related to the study questions following a deductive approach. RESULTS Experts in this study unequivocally emphasized the tragedy for individual patients affected by RFOs. Productivity pressure and the strong economization of operating rooms were perceived as detrimental to safety culture, which was seen as essential for RFO prevention, specifically by those working in the OR. RFOs were seen as "maximally minimizable" but not completely preventable. There was strong agreement that within country differences in RFO risk between Swiss hospitals existed. On the systems level and compared to other safety issues, RFO were having less urgency for most experts. The international comparison of RFO incidences raised serious skepticism across all groups of experts. The validity of the data was questioned and the dominant interpretation of Switzerland's high RFO incidence compared to other countries was a "reporting artifact" based on high coding quality in Swiss hospitals. While most experts thought that the published RFO incidence warrants in-depth analysis of the data, there was little agreement about who's role it was to initiate any further activities. CONCLUSIONS This investigation offers valuable insights into the perspectives of significant stakeholders concerning RFOs, their root causes, and preventability. The findings demonstrate how international comparative safety data are perceived, interpreted, and utilized by national experts to derive conclusive insights.
Collapse
Affiliation(s)
- David Schwappach
- Institute of Social and Preventive Medicine, University of Bern, Mittelstrasse 43, 3012, Bern, Switzerland.
| | | |
Collapse
|
6
|
Bowman CL, De Gorter R, Zaslow J, Fortier JH, Garber G. Identifying a list of healthcare 'never events' to effect system change: a systematic review and narrative synthesis. BMJ Open Qual 2023; 12:e002264. [PMID: 37364940 PMCID: PMC10314656 DOI: 10.1136/bmjoq-2023-002264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 05/23/2023] [Indexed: 06/28/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Cara L Bowman
- Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ontario, Canada
| | - Ria De Gorter
- Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ontario, Canada
| | - Joanna Zaslow
- Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ontario, Canada
| | - Jacqueline H Fortier
- Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ontario, Canada
| | - Gary Garber
- Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ontario, Canada
- Department of Medicine, and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
7
|
Arad D, Rosenfeld A, Magnezi R. Factors contributing to preventing operating room "never events": a machine learning analysis. Patient Saf Surg 2023; 17:6. [PMID: 37004090 PMCID: PMC10067209 DOI: 10.1186/s13037-023-00356-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 03/09/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND A surgical "Never Event" is a preventable error occurring immediately before, during or immediately following surgery. Various factors contribute to the occurrence of major Never Events, but little is known about their quantified risk in relation to a surgery's characteristics. Our study uses machine learning to reveal and quantify risk factors with the goal of improving patient safety and quality of care. METHODS We used data from 9,234 observations on safety standards and 101 root-cause analyses from actual, major "Never Events" including wrong site surgery and retained foreign item, and three random forest supervised machine learning models to identify risk factors. Using a standard 10-cross validation technique, we evaluated the models' metrics, measuring their impact on the occurrence of the two types of Never Events through Gini impurity. RESULTS We identified 24 contributing factors in six surgical departments: two had an impact of > 900% in Urology, Orthopedics, and General Surgery; six had an impact of 0-900% in Gynecology, Urology, and Cardiology; and 17 had an impact of < 0%. Combining factors revealed 15-20 pairs with an increased probability in five departments: Gynecology, 875-1900%; Urology, 1900-2600%; Cardiology, 833-1500%; Orthopedics,1825-4225%; and General Surgery, 2720-13,600%. Five factors affected wrong site surgery's occurrence (-60.96 to 503.92%) and five affected retained foreign body (-74.65 to 151.43%): two nurses (66.26-87.92%), surgery length < 1 h (85.56-122.91%), and surgery length 1-2 h (-60.96 to 85.56%). CONCLUSIONS Using machine learning, we could quantify the risk factors' potential impact on wrong site surgeries and retained foreign items in relation to a surgery's characteristics, suggesting that safety standards should be adjusted to surgery's characteristics based on risk assessment in each operating room. . TRIAL REGISTRATION NUMBER MOH 032-2019.
Collapse
Affiliation(s)
- Dana Arad
- Department of Management, Health Management Program, Faculty of Sciences, Bar-Ilan University, Ramat Gan, Israel.
- Patient Safety Division, Ministry of Health, Ramat Gan, Israel.
| | - Ariel Rosenfeld
- Department of Information Science, Bar-Ilan University, Ramat Gan, Israel
| | - Racheli Magnezi
- Department of Management, Health Management Program, Faculty of Sciences, Bar-Ilan University, Ramat Gan, Israel
| |
Collapse
|
8
|
Arad D, Finkelstein A, Rozenblum R, Magnezi R. Perceptions of surgical never events among interdisciplinary clinicians: Implications of a qualitative study for practice. Collegian 2022. [DOI: 10.1016/j.colegn.2022.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
9
|
Serou N, Slight RD, Husband AK, Forrest SP, Slight SP. A Retrospective Review of Serious Surgical Incidents in 5 Large UK Teaching Hospitals: A System-Based Approach. J Patient Saf 2022; 18:358-364. [PMID: 35617594 DOI: 10.1097/pts.0000000000000931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Surgical incidents are the most common serious patient safety incidents worldwide. We conducted a review of serious surgical incidents recorded in 5 large teaching hospitals located in one London NHS trust to identify possible contributing factors and propose recommendations for safer healthcare systems. METHODS We searched the Datix system for all serious surgical incidents that occurred in any operating room, excluding critical care departments, and were recorded between October 2014 and December 2016. We used the London Protocol system analysis framework, which involved a 2-stage approach. A brief description of each incident was produced, and an expert panel analyzed these incidents to identify the most likely contributing factors and what changes should be recommended. RESULTS One thousand fifty-one surgical incidents were recorded, 14 of which were categorized as "serious" with contributing factors relating to task, equipment and resources, teamwork, work environmental, and organizational and management. Operating room protocols were found to be unavailable, outdated, or not followed correctly in 8 incidents studied. The World Health Organization surgical safety checklist was not adhered to in 8 incidents, with the surgical and anesthetic team not informed about faulty equipment or product shortages before surgery. The lack of effective communication within multidisciplinary teams and inadequate medical staffing levels were perceived to have contributed. CONCLUSIONS Multiple factors contributed to the occurrence of serious surgical incidents, many of which related to human failures and faulty equipment. The use of faulty equipment needs to be recognized as a major risk within departments and promptly addressed.
Collapse
Affiliation(s)
| | | | - Andy K Husband
- From the School of Pharmacy, Newcastle University, Newcastle Upon Tyne
| | - Simon P Forrest
- Department of Sociology, Durham University, Durham, United Kingdom
| | | |
Collapse
|
10
|
Pandit AS, de Gouveia M, Horsfall HL, Reka A, Marcus HJ. Efficacy of a Mindfulness-Based Intervention in Ameliorating Inattentional Blindness Amongst Young Neurosurgeons: A Prospective, Controlled Pilot Study. Front Surg 2022; 9:916228. [PMID: 35599807 PMCID: PMC9122266 DOI: 10.3389/fsurg.2022.916228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 04/22/2022] [Indexed: 11/18/2022] Open
Abstract
Background Human factors are increasingly being recognised as vital components of safe surgical care. One such human cognitive factor: inattention blindness (IB), describes the inability to perceive objects despite being visible, typically when one’s attention is focused on another task. This may contribute toward operative ‘never-events’ such as retained foreign objects and wrong-site surgery. Methods An 8-week, mindfulness-based intervention (MBI) programme, adapted for surgeons, was delivered virtually. Neurosurgical trainees and recent staff-appointees who completed the MBI were compared against a control group, matched in age, sex and grade. Attention and IB were tested using two operative videos. In each, participants were first instructed to focus on a specific part of the procedure and assessed (attention), then questioned on a separate but easily visible aspect within the operative field (inattention). If a participant were ‘inattentionally blind’ they would miss significant events occurring outside of their main focus. Median absolute error (MAE) scores were calculated for both attention and inattention. A generalised linear model was fitted for each, to determine the independent effect of mindfulness intervention on MAE. Results Thirteen neurosurgeons completed the mindfulness training (age, 30 years [range 27–35]; female:male, 5:8), compared to 15 neurosurgeons in the control group (age, 30 years [27–42]; female:male, 6:9). There were no significant demographic differences between groups. MBI participants demonstrated no significant differences on attention tasks as compared to controls (t = −1.50, p = 0.14). For inattention tasks, neurosurgeons who completed the MBI had significantly less errors (t = −2.47, p = 0.02), after adjusting for participant level and video differences versus controls. We found that both groups significantly improved their inattention error rate between videos (t = −11.37, p < 0.0001). In spite of this, MBI participants still significantly outperformed controls in inattention MAE in the second video following post-hoc analysis (MWU = 137.5, p = 0.05). Discussion Neurosurgeons who underwent an eight-week MBI had significantly reduced inattention blindness errors as compared to controls, suggesting mindfulness as a potential tool to increase vigilance and prevent operative mistakes. Our findings cautiously support further mindfulness evaluation and the implementation of these techniques within the neurosurgical training curriculum.
Collapse
Affiliation(s)
- Anand S. Pandit
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
- Correspondence: Anand S. Pandit
| | - Melissa de Gouveia
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Hugo Layard Horsfall
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - Arisa Reka
- UCL Medical School, London, United Kingdom
| | - Hani J. Marcus
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| |
Collapse
|
11
|
Ferorelli D, Benevento M, Vimercati L, Spagnolo L, De Maria L, Caputi A, Zotti F, Mandarelli G, Dell'Erba A, Solarino B. Improving Healthcare Workers' Adherence to Surgical Safety Checklist: The Impact of a Short Training. Front Public Health 2022; 9:732707. [PMID: 35211450 PMCID: PMC8860967 DOI: 10.3389/fpubh.2021.732707] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 12/30/2021] [Indexed: 12/04/2022] Open
Abstract
Background Although surgery is essential in healthcare, a significant number of patients suffer unfair harm while undergoing surgery. Many of these originate from failures in non-technical aspects, especially communication among operators. A surgical safety checklist is a simple tool that helps to reduce surgical adverse events, but even if it is fast to fill out, its compilation is often neglected by the healthcare workers because of unprepared cultural background. The present study aims to value the efficacy of a free intervention, such as a short training about risk management and safety checklist, to improve checklist adherence. Methods In March 2019, the medical and nursing staff of the General Surgical Unit attended a two-lesson theoretical training concerning surgical safety and risk management tools such as the surgical safety checklist. The authors compared the completeness of the surgical checklists after and before the training, considering the same period (2 months) for both groups. Result The surgical safety checklists were present in 198 cases (70.97%) before the intervention and 231 cases (96.25%) after that. After the training, the compilation adherence increased for every different type of healthcare worker of the unit (surgeons, nurses, anesthetists, and scrab nurses). Furthermore, a longer hospitalization was associated with a higher surgical checklist adherence by the operators. Conclusions The results showed that a free and simple intervention, such as a two-lesson training, significantly stimulated the correct use of the surgical safety checklist. Moreover, the checklist adherence increased even for the operators who did not attend the training, maybe because of the positive influence of the colleagues' positive behaviors. As the results were promising with only two theoretical lessons, much more can be done to build a new safety culture in healthcare.
Collapse
Affiliation(s)
- Davide Ferorelli
- Section of Legal Medicine, Department of Interdisciplinary Medicine, University of Bari, Bari, Italy
| | - Marcello Benevento
- Section of Legal Medicine, Department of Interdisciplinary Medicine, University of Bari, Bari, Italy
| | - Luigi Vimercati
- Section of Occupational Medicine, Department of Interdisciplinary Medicine, University of Bari, Bari, Italy
| | - Lorenzo Spagnolo
- Section of Legal Medicine, Department of Interdisciplinary Medicine, University of Bari, Bari, Italy
| | - Luigi De Maria
- Section of Occupational Medicine, Department of Interdisciplinary Medicine, University of Bari, Bari, Italy
| | - Antonio Caputi
- Section of Occupational Medicine, Department of Interdisciplinary Medicine, University of Bari, Bari, Italy
| | - Fiorenza Zotti
- Section of Clinical Risk Management, Policlinico University Hospital of Bari, Bari, Italy
| | - Gabriele Mandarelli
- Section of Criminology and Forensic Psychiatry, Department of Interdisciplinary Medicine, University of Bari, Bari, Italy
| | - Alessandro Dell'Erba
- Section of Legal Medicine, Department of Interdisciplinary Medicine, University of Bari, Bari, Italy
| | - Biagio Solarino
- Section of Legal Medicine, Department of Interdisciplinary Medicine, University of Bari, Bari, Italy
| |
Collapse
|
12
|
Schwappach DLB, Pfeiffer Y. Registration and Management of "Never Events" in Swiss Hospitals-The Perspective of Clinical Risk Managers. J Patient Saf 2021; 17:e1019-e1025. [PMID: 32590527 PMCID: PMC8612887 DOI: 10.1097/pts.0000000000000741] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In Switzerland, there is no mandatory reporting of "never events." Little is known about how hospitals in countries with no "never event" policies deal with these incidents in terms of registration and analyses. OBJECTIVE The aim of our study was to explore how hospitals outside mandatory "never event" regulations identify, register, and manage "never events" and whether practices are associated with hospital size. METHODS Cross-sectional survey data were collected from risk managers of Swiss acute care hospitals. RESULTS Clinical risk managers representing 95 hospitals completed the survey (55% response rate). Among responding risk and quality managers, only 45% would be formally notified through a designated reporting channel if a "never event" has happened in their hospital. Averaged over a list of 8 specified events, only half of hospitals could report a systematic count of the number of events. Hospital size was not associated with "never event" management. Respondents reported that their hospital pays "too little attention" to the recording (46%), the analysis (34%), and the prevention (40%) of "never events." All respondents rated the systematic registration and analysis of "never events" as very (81%) or rather important (19%) for the improvement of patient safety. CONCLUSIONS A substantial fraction of Swiss hospitals do not have valid data on the occurrence of "never events" available and do not have reliable processes installed for the registration and exam of these events. Surprisingly, larger hospitals do not seem to be better prepared for "never events" management.
Collapse
Affiliation(s)
- David L. B. Schwappach
- From the Swiss Patient Safety Foundation, Zurich
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | | |
Collapse
|
13
|
Osborne SR, Cockburn T, Davis J. Exploring Risk, Antecedents and Human Costs of Living with a Retained Surgical Item: A Narrative Synthesis of Australian Case Law 1981-2018. J Multidiscip Healthc 2021; 14:2397-2413. [PMID: 34511923 PMCID: PMC8421039 DOI: 10.2147/jmdh.s316166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 07/13/2021] [Indexed: 12/19/2022] Open
Abstract
Objectives This study aimed to critically examine the circumstances contributing to, and the human costs arising from, the retention of surgical items through the lens of Australian case law. Design Setting and Participants We reviewed Australian cases from 1981 to 2018 to establish a pattern of antecedents and identify long-term patient impacts (human costs) of retained surgical items. We used a modified four-step process to conduct a systematic review of legal doctrine, combined with a narrative synthesis approach to bring the information together for understanding. We searched LexisNexis, AustLII, Coroner Court websites, Australian Health Practitioner Regulation Agency Tribunal Decisions and Panel Hearings, Civil and Administrative Tribunal summaries, and other online sources for publicly available civil cases, medical disciplinary cases, coronial cases, and criminal cases across all Australian jurisdictions. Results Ten cases met the inclusion criteria, including one coronial case, three civil appeal cases, and six civil first instance cases. Time from item retention to discovery ranged from 12 days to 20 years, with surgical sponges the most frequently retained item. Five case reports indicated possible deviations from standard protocols regarding counting procedures and record-keeping. In the four cases that reported on count status, the count was deemed correct at the end of surgery. Case reports also showed the human costs of retained surgical items, that is, the long-term impacts on patients associated with a retained surgical item. In eight of the nine civil cases, ongoing pain was the most frequently reported physical symptom; in three cases, patients suffered psychosocial symptoms requiring treatment. Conclusion While there was little uniformity in the items retained or how items came to be retained, we identified significant time delays between item retention and item discovery, coupled with long-lasting physical and psychosocial harms suffered by patients living with a retained surgical item. Current prevention strategies, including national standards-based professional practices, are not always effective in preventing retained surgical items. An internationally standardised taxonomy and reporting criteria, more consistent reporting, and open access to event and risk data could inform a more accurate global estimate of risk and incidence of this hospital-acquired complication.
Collapse
Affiliation(s)
- Sonya R Osborne
- School of Nursing and Midwifery, Faculty of Health, Engineering and Sciences, Centre for Health Research, Institute for Resilient Regions, University of Southern Queensland, Ipswich, Queensland, Australia
| | - Tina Cockburn
- Australian Centre for Health Law Research, Faculty of Business and Law, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Juliet Davis
- Griffith Criminology Institute, Griffith University, Mt Gravatt, Queensland, Australia
| |
Collapse
|
14
|
Olivarius-McAllister J, Pandit M, Sykes A, Pandit JJ. How can Never Event data be used to reflect or improve hospital safety performance? Anaesthesia 2021; 76:1616-1624. [PMID: 33932033 DOI: 10.1111/anae.15476] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2021] [Indexed: 11/29/2022]
Abstract
The absolute number of Never Events is used by UK regulators to help assess hospital safety performance, without account of hospital workload. We applied funnel plots, as an established means of taking workload into account, to published Never Event data for 151 acute Trusts in NHS England, matched to finished consultant episodes for 3 years, 2017-2020. Trusts with excess event rates should have the most Never Events if absolute number is a valid way to judge performance. The absolute number of Never Events was correlated with workload (r2 = 0.51, p < 0.001), but the five Trusts above the upper 95% confidence limit did not have the highest number of Never Events. However, a limitation to interpretation was that the data were skewed; 12 out of 151 Trusts lay below the lower 95% limit. This skew probably arises because funnel plots pool all Never Events and workload data; whereas, ideally, different Never Events should use as denominator only the relevant workload actions that could cause them. We conclude that the manner in which Never Event data are currently used by regulators, in part to judge or rate hospitals, is mathematically invalid. The focus should shift from identifying 'outlier' hospitals to reducing the overall national mean Never Event rate through shared learning and an integrated system-wide approach.
Collapse
Affiliation(s)
- J Olivarius-McAllister
- Department of Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - M Pandit
- Department of Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A Sykes
- Department of Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Department of Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - J J Pandit
- Nuffield Department of Anaesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,University of Oxford, Oxford, UK
| |
Collapse
|
15
|
Devlin M, Smith AF. 'Never Events': will they always be with us? Anaesthesia 2021; 76:1563-1566. [PMID: 33858027 DOI: 10.1111/anae.15481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2021] [Indexed: 11/28/2022]
Affiliation(s)
- M Devlin
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
| | - A F Smith
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
| |
Collapse
|
16
|
Hypopharyngeal packing during adenotonsillectomy by cold dissection in children: a randomized controlled trial. Eur Arch Otorhinolaryngol 2020; 277:2603-2609. [PMID: 32430771 DOI: 10.1007/s00405-020-06032-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 05/01/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Nausea and vomiting occur in up to 70% of children after adenotonsillectomy, ingested blood during procedure being one of the reasons for emesis. Hypopharyngeal packing (HP) is a common practice among otolaryngologists to prevent blood from being swallowed, but studies in nasal surgeries in adults failed to show efficacy of this technique in reducing postoperative nausea and vomiting (PONV). There are no studies evaluating the effect of HP in adenotonsillectomy in children. The aim of this study is to evaluate the efficacy HP during adenotonsillectomy in children in the prevention of PONV. METHODS This is a randomized, double-blinded, controlled trial. Children aged 4-16 years, scheduled for adenotonsillectomy due to sleep-disordered breathing were enrolled in Hospital da Criança Santo Antônio (Brazil). 192 participants were screened, while 129 were enrolled and completed follow-up for primary outcome. Patients were randomized in a consecutive manner to receive HP or not during adenotonsillectomy. PONV occurrence was assessed in the first 24 h after surgery in HP and control group and relative risk with 95% confidence interval was calculated. RESULTS There were 129 patients randomized, 64 in the HP and 65 in the control group. Female were 40.3% and mean ± SD age was 7.3 ± 2.9. Baseline characteristics and surgery variables were distributed similarly between the groups. Incidence of PONV was 20.3% in the HP and 23.1% in the control group. The relative risk for PONV was 0.88 (95% CI 0.46-1.70). CONCLUSION Our results suggest that there is no benefit of HP during adenotonsillectomy in children for the prevention of PONV. TRIAL REGISTRATION Brazilian Register of Randomized Trials (REBEC) identifier: RBR-3zjn27; Universal Trial Number U1111-1197-7461.
Collapse
|
17
|
Koleva SI. A literature review exploring common factors contributing to Never Events in surgery. J Perioper Pract 2020; 30:256-264. [PMID: 31916908 DOI: 10.1177/1750458919886182] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This literature review explores some common factors contributing to Never Events in surgery. Despite significant patient safety efforts, serious preventable surgical events that turn into Never Events continue to exist. Various search databases were used to collect relevant contemporary data within the time parameters 2008-2019. The literature revealed numerous studies from the United States of America and worldwide, and the need for more current research from the United Kingdom on the subject. The key findings emphasise that communication failure, situational awareness, fatigue, lack of healthcare professionals and surgical caseload are common contributing factors to Never Events. The implications of these findings for practice highlight that despite multidisciplinary approaches, technologies, policies and strategies, Never Events are a common phenomenon in surgery. To minimise their occurrence, more robust and reliable safety management systems need to be in place within healthcare organisations. In depth understanding of cognitive Human Factors and non-technical skills need to be encouraged through education, training and continuous evaluation of success and failure.
Collapse
|
18
|
Wain H, Kong V, Bruce J, Laing G, Clarke D. Analysis of Surgical Adverse Events at a Major University Hospital in South Africa. World J Surg 2019; 43:2117-2122. [DOI: 10.1007/s00268-019-05008-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
19
|
Smith AF, Plunkett E. People, systems and safety: resilience and excellence in healthcare practice. Anaesthesia 2019; 74:508-517. [PMID: 30585298 PMCID: PMC6766951 DOI: 10.1111/anae.14519] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2018] [Indexed: 11/28/2022]
Abstract
This article outlines recent developments in safety science. It describes the progression of three 'ages' of safety, namely the 'age of technology', the 'age of human factors' and the 'age of safety management'. Safety science outside healthcare is moving from an approach focused on the analysis and management of error ('Safety-1') to one which also aims to understand the inherent properties of safety systems that usually prevent accidents from occurring ('Safety-2'). A key factor in the understanding of safety within organisations relates to the distinction between 'work as imagined' and 'work as done'. 'Work as imagined' assumes that if the correct standard procedures are followed, safety will follow as a matter of course. However, staff at the 'sharp end' of organisations know that to create safety in their work, variability is not only desirable but essential. This positive adaptability within systems that allows good outcomes in the presence of both favourable and adverse conditions is termed resilience. We argue that clinical and organisational work can be made safer, not only by addressing negative outcomes, but also by fostering excellence and promoting resilience. We outline conceptual and investigative approaches for achieving this that include 'appreciative inquiry', 'positive deviance' and excellence reporting.
Collapse
Affiliation(s)
| | - E. Plunkett
- University Hospitals Birmingham NHS Foundation TrustBirminghamUK
| |
Collapse
|
20
|
Sivia DS, Pandit JJ. Mathematical model of the risk of drug error during anaesthesia: the influence of drug choices, injection routes, operation duration and fatigue. Anaesthesia 2019; 74:992-1000. [DOI: 10.1111/anae.14629] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2019] [Indexed: 12/16/2022]
Affiliation(s)
| | - J. J. Pandit
- Nuffield Department of Anaesthesia Oxford University Hospitals NHS Trust Oxford UK
| |
Collapse
|
21
|
Harrop-Griffiths W. Never events: on their 10th anniversary, do we need a new name? Br J Hosp Med (Lond) 2019; 80:124-125. [DOI: 10.12968/hmed.2019.80.3.124] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- William Harrop-Griffiths
- Consultant Anaesthetist, Department of Anaesthesia, Imperial College Healthcare NHS Trust, London W2 1NY
| |
Collapse
|
22
|
Pandit JJ, Danbury C. How Do We Eliminate, Or Reduce the Incidence Of, Wrong-Side Anaesthetic Blocks? Anaesth Intensive Care 2018; 46:445-447. [DOI: 10.1177/0310057x1804600502] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
23
|
Affiliation(s)
- A Bodenham
- On behalf of the AAGBI Safe Vascular Access Working Party
| |
Collapse
|
24
|
Abstract
PURPOSE OF REVIEW Many possible hazards bedevil the perioperative patient. This review focuses on a number of aspects of perioperative management where the patient's quality and safety can be enhanced. RECENT FINDINGS Our understanding of the relationship between preoperative preparation and postoperative outcomes has improved. There have also been recent developments in our understanding of how to construct useful cognitive aids and make the best use of checklists by understanding the cultural environment supporting their use. Postoperatively, the concept of 'failure to rescue' in the surgical patients has been explored. SUMMARY A clear vision of what postoperative recovery should mean for practitioner and patients; careful risk stratification and prophylactic measures to avoid postoperative complications; the judicious use of checklists and other cognitive aids to complement clinical expertise in promoting safety within each local context; and the prompt recognition and rescue of postoperative problems when they occur are all important aspects of a safe perioperative care.
Collapse
|
25
|
Bailey CR, Nouraie R, Huitink JM. Have we reached the end for throat packs inserted by anaesthetists? Anaesthesia 2018; 73:535-538. [DOI: 10.1111/anae.14168] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- C. R. Bailey
- Department of Anaesthesia; Guys and St Thomas' NHS Foundation Trust; London UK
| | - R. Nouraie
- Department of Otolaryngology, Head and Neck Surgery; Auckland District Health Board; Auckland New Zealand
| | - J. M. Huitink
- Department of Anesthesiology; VU University Medical Center and Airway Management Academy; Amsterdam The Netherlands
| |
Collapse
|
26
|
Athanassoglou V, Patel A, McGuire B, Higgs A, Dover MS, Brennan PA, Banerjee A, Bingham B, Pandit JJ. Systematic review of benefits or harms of routine anaesthetist-inserted throat packs in adults: practice recommendations for inserting and counting throat packs: An evidence-based consensus statement by the Difficult Airway Society (DAS), the British Association of Oral and Maxillofacial Surgery (BAOMS) and the British Association of Otorhinolaryngology, Head and Neck Surgery (ENT-UK). Anaesthesia 2018; 73:612-618. [PMID: 29322502 DOI: 10.1111/anae.14197] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2017] [Indexed: 11/27/2022]
Abstract
Throat packs are commonly inserted by anaesthetists after induction of anaesthesia for dental, maxillofacial, nasal or upper airway surgery. However, the evidence supporting this practice as routine is unclear, especially in the light of accidentally retained throat packs which constitute 'Never Events' as defined by NHS England. On behalf of three relevant national organisations, we therefore conducted a systematic review and literature search to assess the evidence base for benefit, and also the extent and severity of complications associated with throat pack use. Other than descriptions of how to insert throat packs in many standard texts, we could find no study that sought to assess the benefit of their insertion by anaesthetists. Instead, there were many reports of minor and major complications (the latter including serious postoperative airway obstruction and at least one death), and many descriptions of how to avoid complications. As a result of these findings, the three national organisations no longer recommend the routine insertion of throat packs by anaesthetists but advise caution and careful consideration. Two protocols for pack insertion are presented, should their use be judged necessary.
Collapse
Affiliation(s)
- V Athanassoglou
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A Patel
- The Royal National Throat Nose and Ear Hospital, London, UK
| | | | - A Higgs
- Warrington Hospitals NHS Foundation Trust, Cheshire, UK
| | - M S Dover
- Queen Elizabeth Hospital, Birmingham, UK
| | - P A Brennan
- Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - A Banerjee
- James Cook University Hospital, Middlesbrough, UK
| | | | - J J Pandit
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| |
Collapse
|
27
|
Hopping M, Merry AF, Pandit JJ. Exploring performance of, and attitudes to, Stop- and Mock-Before-You-Block in preventing wrong-side blocks. Anaesthesia 2017; 73:421-427. [DOI: 10.1111/anae.14167] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2017] [Indexed: 11/29/2022]
Affiliation(s)
- M. Hopping
- School of Medicine; Faculty of Medical and Health Sciences; The University of Auckland; New Zealand
- Nuffield Department of Anaesthetics; Oxford University Hospitals NHS Foundation Trust; Oxford UK
| | - A. F. Merry
- School of Medicine; Faculty of Medical and Health Sciences; The University of Auckland; New Zealand
- Department of Anaesthesia; Auckland City Hospital; Auckland New Zealand
| | - J. J. Pandit
- Nuffield Department of Anaesthetics; Oxford University Hospitals NHS Foundation Trust; Oxford UK
| |
Collapse
|
28
|
Affiliation(s)
- I K Moppett
- Anaesthesia and Critical Care Section, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - S T Shorrock
- Centre for Human Factors and Sociotechnical Systems, University of the Sunshine Coast, Qld, Australia
| |
Collapse
|
29
|
Affiliation(s)
| | - A Allan
- Great Western Hospital, Swindon, UK
| |
Collapse
|
30
|
Affiliation(s)
| | | | - M. Pandit
- University Hospitals Coventry and Warwickshire NHS Trust; Coventry UK
| |
Collapse
|
31
|
Affiliation(s)
- J. M. Wight
- Guy's and St Thomas' NHS Foundation Trust; London UK
| | - L. Chrisman
- Guy's and St Thomas' NHS Foundation Trust; London UK
| | - I. Reed
- Guy's and St Thomas' NHS Foundation Trust; London UK
| | - G. S. K. Wong
- Guy's and St Thomas' NHS Foundation Trust; London UK
| | - A. Pawa
- Guy's and St Thomas' NHS Foundation Trust; London UK
| |
Collapse
|
32
|
Pandit JJ, Matthews J, Pandit M. “Mock before you block”: an in-built action-check to prevent wrong-side anaesthetic nerve blocks. Anaesthesia 2016; 72:150-155. [DOI: 10.1111/anae.13664] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2016] [Indexed: 11/27/2022]
Affiliation(s)
| | - J. Matthews
- Nuffield Department of Anaesthetics; Oxford University Hospitals NHS Foundation Trust; Oxford UK
| | - M. Pandit
- University Hospitals of Coventry and Warwickshire NHS Trust; Coventry UK
| |
Collapse
|
33
|
Pemberton MN. Surgical safety checklists and understanding of Never Events, in UK and Irish dental hospitals. Br Dent J 2016; 220:585-9. [DOI: 10.1038/sj.bdj.2016.414] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2016] [Indexed: 11/09/2022]
|
34
|
Affiliation(s)
- Iain K Moppett
- Macintosh Professor in the Department of Anaesthesia and Critical Care, Division of Clinical Neuroscience, University of Nottingham and Honorary Consultant Anaesthetist in the Department of Anaesthesia, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH
| | - Sarah H Moppett
- Divisional Nurse in Clinical Support, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham
| |
Collapse
|
35
|
Affiliation(s)
- M. A. Smith
- University of Newcastle upon Tyne; Newcastle UK
| | | |
Collapse
|
36
|
Moppett I, Moppett S. Better names for Never Events - a reply. Anaesthesia 2016; 71:602. [DOI: 10.1111/anae.13478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- I. Moppett
- Nottingham University Hospitals NHS Trust; Nottingham UK
| | - S. Moppett
- Nottingham University Hospitals NHS Trust; Nottingham UK
| |
Collapse
|
37
|
Wahid NNA, Moppett SH, Moppett IK. Quality of Quality Accounts: transparency of public reporting of Never Events in England. A semi-quantitative and qualitative review. J R Soc Med 2016; 109:190-9. [PMID: 26933157 DOI: 10.1177/0141076816636367] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To describe the quality of reporting and investigation into surgical Never Events in public reports. DESIGN Semi-quantitative and qualitative review of published Quality Accounts for three years (2011/2-2013/14). Data on Never Events were compared with previously collated Never Events rates. Quality of reported investigations was assessed using the London Protocol. SETTING English National Health Service. PARTICIPANTS All English acute hospital trusts. MAIN OUTCOME MEASURES Quality of Never Event reporting. RESULTS Quality Accounts were available for all Trusts for all three years, of which 342 referred to years when a surgical Never Event had occurred. A total of 125 of 342 (37%) accounts failed to report any or all Never Events that had occurred; 13/342 (4%) provided full disclosure; 197 (58%) reported that some investigation had taken place. Of these 197, 61 (31%) were limited in scope; 61 (31%) were categorised as detailed reports. Task and Technology factors were the commonest factor (103/211 (49%)) Identified in investigations, followed by Individual factors (48/211 (23%)). Team and Work environment factors were identified in 29/211 (14%) and 23/211 (11%), respectively. Organisational and Management 5/211 (2%) factors were rarely identified, and the Institutional context was never discussed. CONCLUSIONS Reporting of Never Events and their investigations by English NHS Trusts in their Quality Accounts is neither consistently transparent nor adequate. As with clinical error, the true root causes are likely to be organisational rather than individual.
Collapse
Affiliation(s)
| | - Sarah H Moppett
- Queen's Medical Centre, Nottingham University Hospitals, Nottingham NG7 2UH, UK
| | - Iain K Moppett
- Anaesthesia & Critical Care Section, Division of Clinical Neuroscience, Queen's Medical Centre, Nottingham University Hospitals, University of Nottingham, NG7 2UH, UK
| |
Collapse
|
38
|
Pandit JJ. Deaths by horsekick in the Prussian army - and other ‘Never Events’ in large organisations. Anaesthesia 2015; 71:7-11. [DOI: 10.1111/anae.13261] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- J. J. Pandit
- Nuffield Department of Anaesthetics; Oxford University Hospitals NHS Trust UK
- St John's College; Oxford
| |
Collapse
|