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.

Registration and Management of "Never Events" in Swiss Hospitals-The Perspective of Clinical Risk Managers

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.

[Transcultural adaptation of AGRASS questionnaire to evaluate the management of heathcare risks]

OBJECTIVE

To cross-culturally adapt the Questionário AGRASS for evaluation of healthcare risk management in health services.

MATERIAL AND METHODS

The work was carried out following 5 stages: 1) initial translation to Spanish; 2) Synthesis; 3) translation back to Portuguese; 4) experts review, and 5) pretest performed in a specialized Costa Rican hospital.

RESULTS

The AGRASS Questionnaire translated and adapted into Spanish has the same dimensional structure as the original, with 2 dimensions and 9 subdimensions. Thirty-nine of the 40 original items were approved (general validation index=100% per item). Its application was considered viable, with items well understood and with useful results that identify opportunities for improvement in healthcare risk management.

CONCLUSIONS

The AGRASS Questionnaire is culturally adapted to the Costa Rican reality and future studies can evaluate its contribution to other hospital contexts in Ibero-American countries.

Wrong-site nerve blocks: evidence-review and prevention strategies

PURPOSE OF REVIEW

There has been increasing attention to wrong site medical procedures over the last 20 years. This review aims to provide a summary of the current understanding and recommendations for the prevention of wrong-site nerve blocks (WSNB).

RECENT FINDINGS

Various procedural, patient, practitioner, and organizational factors have been associated with the risk of WSNB. Recent findings have suggested that the use of a checklist is likely to reduce the incidence of WSNB. However, despite the widespread use of preprocedural checklists, WSNB continue to occur at significant frequency. This may be due to the inability of practitioners and teams to implement checklists correctly or the cognitive errors that prevent checklists from being executed as designed.

SUMMARY

Though the evidence is limited, it is recommended that a combination of multiple strategies should be employed to prevent WSNB. These include the use of preprocedural markings, well constructed checklists, time-out/stop-moments, and cognitive/physical aids. Effective implementation requires team education and engagement that empowers all team members to speak up as part of a culture of safety.