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Showing results for tags 'Never event'.
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Content ArticleAir flowmeters attached to piped medical air outlets are primarily used to drive the administration of nebulised medication; typically for short periods to manage respiratory conditions. Most other uses of piped medical air do not require an air flowmeter. Due to the proximity of the piped medical air and oxygen outlets at the bedside, and the similarity in design of flowmeters, there is a significant risk when using air flowmeters that patients may be inadvertently connected to medical air instead of oxygen. A previous alert and additional communications have sought to minimise the use of air flowmeters by encouraging their replacement with compressor or ultrasonic nebulisers, alongside additional risk reduction methods if air flowmeters remained in use. However, despite the measures outlined above, 108 Never Events describing unintentional connection were reported in a recent three-year period ; over a third of incidents occurred in emergency departments. Consequences included respiratory arrest, cardiac arrest, collapse (requiring ITU admission and ventilation), and nine incidents of incorrect connection when responding to cardiac arrest, which will have impacted on the chance of successful resuscitation; six patients subsequently died.
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Content ArticleThis study in the Journal of Patient Safety examined how hospitals outside mandatory 'never event' regulations identify, register, and manage 'never events', and whether practices are associated with hospital size. In Switzerland, there is no mandatory reporting of 'never events' and little is known about how hospitals in countries without 'never event' policies deal with these incidents in terms of registration and analyses. The study found that many 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 examination of these events. Surprisingly, larger hospitals do not seem to be better prepared for “never events” management.
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EventNever Events and serious Incidents are a cause for concern and anxiety when reported in an organisation. They require investigation and official reporting to the Care Quality Commision (CQC). The end result should be a process of open multidisciplinary analysis and discussion led by the Clinical Governance team that results in learning for the organisation. This process can be difficult and sensitive when harm is identified and errors attributed to processes and individual staff. In this webinar, we welcome representatives from the CQC and the National Orthopaedic Alliance (NOA) to discuss learning from never events and serious incidents. Register
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Content ArticleA surgical fire is one that occurs in, on or around a patient undergoing a surgical procedure and is an internationally recognised patient safety issue. On 16 December 2021, Members of Parliament held a general debate on preventing surgical fires in Westminster Hall. In this article, the Association for Perioperative Practice (AfPP) sets out its response to issues raised in the debate.
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Content ArticleThis is a debate from the House of Commons on 16 December 2021 on the issue of preventing surgical fires in the NHS.
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News Article
Mid and South Essex NHS Foundation Trust told it must improve
Patient Safety Learning posted a news article in News
Changes must be made across services at one of England's biggest NHS trusts following its first wide-ranging inspection, a health watchdog said. Mid and South Essex NHS Foundation Trust - which runs Basildon, Southend and Broomfield hospitals - has been rated as "requires improvement". The Care Quality Commission (CQC) turned up unannounced after concerns over standards were raised. Philippa Styles, the CQC's head of hospital inspection, said they "found a mixed picture" of positive improvements and areas of concern. "Following the trust's formation in 2020, leaders should now be able to work together effectively to ensure care is consistent across all services," she said. "I recognise the enormous pressure NHS services are under... and that usual expectations cannot always be maintained, especially in the urgent and emergency department, but it is important they do all they can to mitigate risks to patient safety." The report said: Patients had not always been protected from harm. Staff had not all received mandatory training. There had been nine "never-should-happen" medical events. Records were sometimes inaccurate and not kept securely. Nursing and medical staffing was a "challenge across the trust", with shifts regularly below planned staffing numbers. There had been a high number of whistle-blowers raising concerns. Read full story Source: BBC News, 1 December 2021 -
Content Article
Surgical fires are a serious a patient safety issue. In this blog, Patient Safety Learning analyses a recent response from Maria Caulfield MP, Minister for Patient Safety and Primary Care, to several questions tabled in the House of Commons about surgical fires in the NHS, and outlines the need for further action to prevent these incidents.- Posted
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Content ArticleTCC-CASEMIX has created a unique infrastructure to provide total traceability of medical device performance. This infrastructure is supported by The Association of British HealthTech Industries [ABHI]. We refer to it as an 'Open Registry Infrastructure' for medical devices. It is 'open', because unlike existing clinically focused registries, which are 'closed', we enable wide searches across the registries connected into it. It is 'open' because registries will 'declare the content' (I don't know what I don't know, so how can I search for what I don't know?) Access to this infrastructure is through a Data Access Portal which is being configured for the specific needs of each stakeholder group. We are seeking interest from patient groups who would like to join an Advisory Board to help specify how data should be presented to patients in a way that is relevant and meaningful. Our vision is to link this portal into an enhanced pre-operative assessment process, and to transform patient informed consent.
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Content Article
WireSafe® is an innovative solution designed to prevent retained guidewires during central venous catheter (CVC) insertion. Retained guidewires are never events that require urgent removal if accidentally left in. They occur in about 1 in 300,000 procedures. We interviewed Maryanne, who developed the WireSafe®, on the innovation, the human factor considerations in designing it and the difficulties she faced getting a new product into the NHS. -
Content Article
This competency framework has been developed and updated to support prescribers in expanding their knowledge, skills, motives and personal traits, to continually improve their performance, and work safely and effectively. -
Content Article
Patient safety poster: Air flow meters
PatientSafetyLearning Team posted an article in Improving patient safety
The unintentional connection of a patient requiring oxygen to an air flowmeter is listed by the NHS as a 'Never Event'. The patient safety notice poster below (and attached for better viewing) has been developed by Sandwell and West Birmingham NHS Trust, to help raise awareness among staff and prevent future errors. Do you use posters or infographics to improve patient safety locally? Why not get in touch by emailing content@patientsafetylearning.org, to share your examples more widely on the hub. -
Content ArticleThis article describes how Never Events (NE) are serious clinical incidents that cause harm to patients. The authors analysed data from NHS England to categorise themes and identify common NE. Their results revealed 51 common NE themes in four main categories out of a total of 3247 between 2012 and 2020, identifying wrong-site surgery as the most common category. The authors conclude that with this research, awareness may help to reduce the amount of incidences in the future.
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Content ArticleIn February 2021, the list of never events was updated to exclude wrong tooth extraction, as the systemic barriers to prevent these incidents were not considered ‘strong enough.’ In this article, published in the British Journal of Oral and Maxillofacial Surgery, authors discuss the matter, and provide some recommendations to minimise the risk of wrong tooth extraction.
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Content ArticleNever Events are defined by the NHS as patient safety incidents that are wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and have been implemented by healthcare providers. This study considers how effective using of the absolute number of Never Events that take place at English hospital trusts, without accounting for hospital workload, is for judging their underlying safety performance and safety culture. In its conclusions the authors suggest that there are flaws in the current approach regulators take to using Never Events data to judge hospital performance.
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Content ArticleDespite widespread recognition and known harms, serious surgical errors, known as surgical never events, endure. The California Department of Public Health (CDPH) has developed an oversight system to capture never events and a platform for process improvement that has not yet been critically appraised. This study examined surgical never events occurring in hospitals in California and summarize recommendations to prevent future events.
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News Article
Alert over hospital air devices after 120 ‘never events’
Patient Safety Learning posted a news article in News
NHS trusts are to be told to remove devices linked to more than 120 never events caused by ‘unconscious errors’. A national patient safety alert from NHS England which urges trusts to remove all air flowmeters from wall medical gas outlets. It is likely to be published next month. The alert comes after 121 never events in the last three years involved staff members accidentally connecting patients to air instead of oxygen. This number is close to 10% of all never events recorded during that period. These types of never events have been recorded by 57 NHS organisations during 2018-19, 2019-20 and 2020-21. The incidents took place mostly on medical wards and in emergency departments. They occurred despite NHSE issuing a patient safety alert in 2016, which recommended removing the flowmeters from wall outlets when not in active use. According to NHSE documents - seen by HSJ - the never events often went undetected “for some time”, even when other staff responded to deteriorating patients or took over their care. The regulator concluded this makes it more likely that there have been other unreported incidents. Read full story (paywalled) Source: HSJ, 17 May 2021 -
Content ArticleThis report by The Right Reverend James Jones KBE aims to provide an insight into what the bereaved Hillsborough families experienced in the years following the Hillsborough disaster in April 1989. It seeks to place their insight on the official public record in the hope that their suffering and experience will bring about changes to the way in which public institutions treat people who have been bereaved. It records family members' experiences of interacting with the authorities after the disaster and around the different inquests, and highlights 25 points of learning for public institutions.
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Content ArticleUse of misplaced nasogastric and orogastric tubes was first recognised as a patient safety issue by the National Patient Safety Agency (NPSA) in 2005 and three further alerts were issued by the NPSA and NHS England between 2011 and 2013. Introducing fluids or medication into the respiratory tract or pleura via a misplaced nasogastric or orogastric tube is a Never Event. Never Events are considered ‘wholly preventable where guidance or safety recommendations that provide strong systemic protective barrier are available at a national level, and should have been implemented by all healthcare providers.’ Between September 2011 and March 2016, 95 incidents were reported to the National Reporting and Learning System (NRLS) and/or the Strategic Executive Information System (StEIS) where fluids or medication were introduced into the respiratory tract or pleura via a misplaced nasogastric or orogastric tube. While this should be considered in the context of over 3 million nasogastric or orogastric tubes being used in the NHS in that period, these incidents show that risks to patient safety persist. Checking tube placement before use via pH testing of aspirate and, when necessary, x-ray imaging, is essential in preventing harm.
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Content ArticleThis article looks at NHS safety advice on reducing the harm caused by nasogastric feeding tubes that have been wrongly inserted. The alert, from the National Patient Safety Agency, followed 11 deaths of patients in two years, including that of one child.
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Content Article
Nasogastric tube safety: it’s personal
PatientSafetyLearning Team posted an article in Improving patient safety
Dr Frances Healey provides her personal perspective on the continuing persistence of harm caused by misplaced nasogastric tubes from her experience both as a nurse and head of patient safety insight at NHS Improvement. -
Content ArticleMisplacement of nasogastric tubes can have disastrous consequences for patients and is listed as a “never event” by NHS England. When Lancashire Teaching Hospitals NHS Foundation Trust had two of these never events, the nutrition nursing team carried out a system-wide evaluation to identify problems and develop plans to address them. An e-learning package, robust standardisation in staff’s approach to patient care, re-setting “red lines” to support and empower staff, and the introduction of monitoring and reporting systems have contributed to improving patient safety.
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Content ArticleThis position paper was prepared by the Nasogastric Tube Special Interest Group of BAPEN. Dr Trevor Smith, BAPEN President commented: “It is essential that patient safety is at the top of the agenda of every NHS Trust and Health Board. Nobody in need of artificial nutrition should be at risk of a Never Event, so we endorse the special NGT placement training for a select group of staff in every hospital. Our mission is to ensure everybody receives optimal nutritional care, but it is also important to us to protect frontline healthcare professionals from the risk of avoidable and incredibly distressing mistakes. We hope this paper goes some way to encouraging Trusts and Health Boards to move towards far safer practices.”
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Content ArticleThe MDU’s Michael Devlin argues in this BMJ Opinion article that the never events policy has had a limited effect on patient safety and welcomes a reassessment by the Healthcare Safety Investigation Branch.
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Content ArticleSurgical fires, which in the perioperative environment is a fire that occurs on or in a patient while in the operating theatre, are recognised as an international patient safety concern. This is due to the risks of injury to both patients and healthcare professionals. Surgical fires are categorised as either airway or non-airway and occur most commonly in the head, face, neck, upper chest or during ENT surgical procedures. The Association for Perioperative Practice (AfPP) along with a coalition of patient safety focused organisations are calling for more to be done to prevent surgical fires. Lindsay Keeley, patient safety and quality lead for the AfPP, explains why such incidents must be classified as ‘Never Events’, the common causes of surgical fires and the AfPP recommendations and standards for safe use of devices.
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Event
Zero harm and never events
Sam posted an event in Community Calendar
untilThis Q Community session: Introduces the concepts and origins of ‘never events’ and ‘zero harm’ as safety interventions. Explores and debates the usefulness of ‘never event’ and ‘zero harm’ initiatives as effective safety management strategies in healthcare. Reflects on and considers alternative approaches to managing risks of serious harm to as low as reasonably practicable. Further information Register
