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Showing results for tags 'Never event'.
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News Article
Trust warned by regulator after cluster of never events
Patient Safety Learning posted a news article in News
The Care Quality Commission has ordered immediate improvements to a trust after it reported six never events inside eight months. The watchdog has issued a warning notice to Royal Cornwall Hospitals Trust after it carried out an announced inspection which focused on the trust’s surgical care group – where six never events had occurred between February and October last year. In November, HSJ reported that a total of eight never events had been recorded in 2020, with trust chief executive Kate Shields saying it had raised fears the trust had not fully embedded safety improvements initiated as part of the special measures regime. The inspectors visited three of the trust’s sites where the never events had happened. These were: Royal Cornwall Hospital in Truro, St Michael’s Hospital in Hayle and West Cornwall Hospital in Penzance. The inspectors reported that governance processes were “not effective enough” to ensure that changes were made across the trust, and that lessons from incidents and near misses were “not shared with the whole team and wider service to ensure patient safety”. Their report also stated the trust’s safety checklist for surgical procedures had improved but was not fully compliant with the World Health Organisation’s standards. However, the CQC found staff apologised and provided patients with information when things had gone wrong, and that there was an open culture in which staff felt able to raise concerns. Read full story (paywalled) Source: HSJ, 17 February 2021 -
Content ArticleA sub-group of rare but serious patient safety incidents, known as ‘never events,’ is judged to be ‘avoidable.’ There is growing interest in this concept in international care settings, including UK primary care. However, issues have been raised regarding the well-intentioned coupling of ‘preventable harm’ with zero tolerance ‘never events,’ especially around the lack of evidence for such harm ever being totally preventable. Bowie et al. consider whether the ideal of reducing preventable harm to ‘never’ is better for patient safety than, for example, the goal of managing risk materialising into harm to ‘as low as reasonably practicable,’ which is well-established in other complex socio-technical systems and is demonstrably achievable. They reflect on the ‘never event’ concept in the primary care context specifically, although the issues and the polarised opinion highlighted are widely applicable. Recent developments to validate primary care ‘never event’ lists are summarised and alternative safety management strategies considered, e.g. Safety-I and Safety-II.
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News Article
Multiple whistleblowers flag ‘heartbreaking’ incidents at major trust
Patient Safety Learning posted a news article in News
Clinicians within a major teaching hospital’s cancer services have raised multiple concerns over patient safety, which they believe have resulted from badly planned service changes in response to the covid crisis. HSJ has spoken to several staff members who have worked in the haematology speciality at University Hospitals Birmingham Foundation Trust since last June, when the services underwent significant changes to free up capacity for coronavirus patients. This involved most haematology services at Heartlands Hospital in east Birmingham moving to the trust’s main Queen Elizabeth Hospital site in Edgbaston. The staff, who all wished to remain anonymous, told HSJ the transfer happened at just one week’s notice and was poorly planned. Once implemented, they said QEH’s newly enlarged service suffered from extreme staffing shortages, leading to several “never events”, such as patients being given the wrong blood type. In one resignation letter, a nurse who had transferred to QEH told managers patients’ “basic care needs are not being met”. The nurse said most shifts were understaffed, with examples of three nurses looking after 30 patients and added in the resignation letter: “I am witnessing strong and knowledgeable colleagues breaking down on each shift. “Furthermore, never events are happening at an alarming rate, necessary resources are commonly unavailable and communication between all levels of seniority is poor…" Read full story (paywalled) Source: HSJ, 2 February 2021 -
Content ArticleThis document defines the investigation framework in the event of a patient safety Serous Incident (SI) related to NHS Wales Informatics Service (NWIS) delivered or supported services, which affects one or more health body in Wales.
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News ArticleAt least seven so-called NHS “never events” should be reclassified because the health service has failed to put in place effective measures to stop them from repeatedly happening, safety experts have said. The independent Healthcare Safety Investigation Branch (HSIB) said NHS England should remove the never event incidents from the list of 15 it requires hospitals to report, because they are not “wholly preventable” and the NHS has not adequately recognised the systemic risks that mean they keep happening. The errors include examples such as a 62-year-old man having the wrong hip replaced during surgery and a nine-year-old girl who was given a drug by injection that should have been given by mouth. Other incidents included a woman who had a vaginal swab left inside her following the birth of her first child and a 26-year-old man who had a feeding tube accidentally inserted into his lung rather than his stomach. In a new report, investigators from HSIB carried out a detailed analysis of seven incidents it has investigated which account for the majority of never events recorded by NHS hospitals in 2018-19. NHS England claims there are steps hospitals can take that mean the errors should never happen but HSIB says many of the steps are administrative, such as a checklist, and do not fully take into account the environment staff work in, the nature of the errors or how they happen. Read full story Source: The Independent, 21 January 2021
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Content Article‘Never events’ are patient safety incidents that are defined as being wholly preventable. They are considered wholly preventable because guidance or safety recommendations are in place at a national level and should have been implemented by all providers in the healthcare system. This should act as a strong systemic barrier to prevent the serious incident from happening. The latest national report from the Healthcare Safety Investigation Branch (HSIB) says that 'Never Events' should not be defined as such if they don’t have strong enough barriers in place to stop them happening.It recommends that seven Never Events on a list of 15 should be removed until better barriers are in place. They are using the Safety Engineering Initiative for Patient Safety (SEIPS) model to carry out the analysis. SEIPS provides a framework for understanding structures, processes and outcomes in healthcare, and their relationships.
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Community Post
Champion clinicians in building AI for surgical safety
Yesh posted a topic in Artificial Intelligence
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Subject: Looking for Clinical Champions (Patient Safety Managers, Risk Managers, Nurses, Frontline clinical staff) to join AI startup Hello colleagues, I am Yesh. I am the founder and CEO of Scalpel. <www.scalpel.ai> We are on a mission to make surgery safer and more efficient with ZERO preventable incidents across the globe. We are building an AI (artificially intelligent) assistant for surgical teams so that they can perform safer and more efficient operations. (I know AI is vaguely used everywhere these days, to be very specific, we use a sensor fusion approach and deploy Computer Vision, Natural Language Processing and Data Analytics in the operating room to address preventable patient safety incidents in surgery.) We have been working for multiple NHS trusts including Leeds, Birmingham and Glasgow for the past two years. For a successful adoption of our technology into the wider healthcare ecosystem, we are looking for champion clinicians who have a deeper understanding of the pitfalls in the current surgical safety protocols, innovation process in healthcare and would like to make a true difference with cutting edge technology. You will be part of a collaborative and growing team of engineers and data scientists based in our central London office. This role is an opportunity for you to collaborate in making a difference in billions of lives that lack access to safe surgery. Please contact me for further details. Thank you Yesh yesh@scalpel.ai
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News ArticleNHS guidance ‘too long to read,’ say hospital staff as safety watchdog exposes systemic risks to patients. The Healthcare Safety Investigation Branch (HSIB) revealed some NHS staff had admitted not reading official guidance on how to avoid the ‘never event’ error as part of a new report identifying deeper systemic problems that it said left patients at an increased risk. The independent body warned patients across the NHS remained vulnerable to being injured or even killed by the error that keeps happening in hospitals despite warnings and safety alerts over the last 15 years. HSIB launched a national investigation into the problem of misplaced nasogastric (NG) tubes after a 26-year-old man had 1,450ml of liquid feed fed into his lungs in December 2018 after a bike accident. The patient recovered but the error was not spotted, even after an X-ray. Read full story Source: The Independent, 17 December 2020
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Content ArticleThe latest Healthcare Safety Investigation Branch (HSIB) report focuses on the life-threatening risk posed by the accidental misplacement of tubes that deliver food or medication to critically ill patients.
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News Article
Trusts warned they are being ‘complacent’ on A&E over-crowding
Patient Safety Learning posted a news article in News
Emergency medics are writing to hospital chief executives warning them that some trusts are being ‘complacent’ about crowding in A&E, they have told HSJ. The Royal College of Emergency Medicine (RCEM) is sending a letter to trust chiefs today calling on them to urgently plan for how they will stop corridor waits and exit blocking ahead of January and February, typically the busiest months. It says some trusts were not treating emergency department crowding as a “high priority”, despite covid risks and pressures. It is also calling for overcrowding in the emergency department (ED) to be classed as a “never event” — a set of major safety risks. RCEM’s concern comes amid apprehension over long ambulance queues at hospitals across the UK, and difficulties enabling social distancing between patients in many EDs. Read full story (paywalled) Source: HSJ, 3 November 2020 -
News Article
Cluster of never events has sparked ‘great deal of soul searching’ says trust CEO
Patient Safety Learning posted a news article in News
An acute trust’s record of eight never events in the last six months has raised concerns that quality standards have slipped since it was taken out of special measures. The never events occurred at Royal Cornwall Hospitals Trust. They included three wrong site surgeries within the same speciality and an extremely rare incident in which a 30cm (15 inch) wire was left in a cardiology patient. Kate Shields, chief executive of the trust, said the incidents have led to a “great deal of soul searching”. Prior to the incidents the trust had gone 13 months without recording a never event, and Ms Shield acknowledged that pressure created by the pandemic was likely to have been a contributing factor behind the cluster of never events. She stressed that none of the patients affected had suffered physical harm. Read full story (paywalled) Source: HSJ, 12 November 2020 -
News ArticleA trust which had four ‘never events’ where patients were connected to air rather than an oxygen supply could have avoided them if it had been more proactive when a national patient safety alert was sent out several years earlier, a report has found. In one case, a baby being investigated for sepsis had oxygen saturation levels of just 75% before the mistake was realised. In another, a woman with COPD and pneumonia had oxygen saturation at 80% when she was connected to the air outlet. Calderdale and Huddersfield Foundation Trust asked the Royal College of Physicians to carry out an invited review after the four never events at Calderdale Royal Hospital in 2018 and 2019. The earliest incident happened in February 2018 but was not identified until a retrospective audit nearly a year later. The RCP’s report said that, had this been identified earlier, “steps could have been put in place to avoid such incidents from subsequently occurring”. But it added: “All four never events could have been avoided if the trust had responded more proactively to the previous NHS Improvement patient safety alert about the dangers of erroneously connecting patients to air instead of oxygen and had subsequently restricted access to air outlets.” Read full story (paywalled) Source: HSJ, 2 November 2020
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News ArticleAn external review has been launched at a leading children’s hospital after a series of “never events”. According to local commissioners, a review by the Association for Perioperative Practitioners will look into seven incidents at Alder Hey Children’s Foundation Trust over the last two years. The probe had been delayed by the pandemic and began this month. Great Ormond Street Hospital for Children FT and Sheffield Children’s FT, the two other dedicated children’s trusts in England, reported one and four never events respectively, between April 2018 and July 2020, according to national data. In a statement, Alder Hey claimed it could not provide further details of the incidents. But most have been described in its board papers over the past year. They include a 15-year-old who had the wrong tooth removed by the surgical division, a patient who had the wrong eye operated on, a swab that was left inside a patient having their adenoids and tonsils removed, and an incorrect implant being inserted into an orthopaedics patient. Liverpool Clinical Commissioning’s group’s board papers for September said: “The trust has had a series of seven never events and there is a plan to undertake an external review that has been delayed due to the pandemic response. The trust has approached the Association for Perioperative Practitioners and have agreed the process." “The trust also plans to work with Imperial College London on a peer review and bespoke human factors training to include simulation training and coaching. The trust also plans to produce an overarching action plan to bring together the themes and learning from the seven never events. This work is still underway and NHSE/I and CCG had requested a copy of this plan.” Read full story (paywalled) Source: HSJ, 24 September 2020
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Content Article
Medical error prevention (5 May 2020)
Sam posted an article in Good practice
Medical errors are a serious public health problem and a leading cause of death in the United States. It is a difficult problem as it is challenging to uncover a consistent cause of errors and, even if found, to provide a consistent viable solution that minimises the chances of a recurrent event. By recognising untoward events occur, learning from them, and working toward preventing them, patient safety can be improved. Part of the solution is to maintain a culture that works toward recognising safety challenges and implementing viable solutions rather than harboring a culture of blame, shame, and punishment. Healthcare organisations need to establish a culture of safety that focuses on system improvement by viewing medical errors as challenges that must be overcome. All individuals on the healthcare team must play a role in making the provision of healthcare safer for patients and healthcare workers. -
Content ArticleWhen you are receiving treatment, it is important to feel that you are in safe hands. The Private Healthcare Information Network (PHIN) website publishes information on a range of patient safety measures, including about serious safety incidents. One category of these are known as Never Events. Here we explain what Never Events are, why they are measured, and how you can use them when considering which hospital is right for you.explain what Never Events are, why they are measured, and how you can use them when considering which hospital is right for you.
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Content ArticleThe Private Healthcare Information Network (PHIN) has published new information about serious patient safety incidents for private acute care. The data, covering the period 1 January 2019 to the 31 December 2019, show that 21 Never Events involving non-NHS (insured or self-pay) patients were reported.
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News ArticleThere were 21 “wholly preventable” patient safety incidents of the most serious category at private hospitals last year, new data has shown, as NHS bosses prepare to invest up to £10bn in the sector. This is the first time that a comprehensive dataset of 'never events’ within private hospitals has been published in the UK, and comes ahead of plans to outsource both inpatient and outpatient services, routine surgery operations and cancer treatment to private providers. The audit conducted by the Private Healthcare Information Network (PHIN), established in 2014 to bring greater transparency to the private health sector, showed that 287 out of 595 private hospitals and NHS private patient units (PPUs) provided information on Never Events between 1 January and 31 December 2019. This group accounts for an estimated 86 per cent of privately-funded admitted patient care, PHIN said. It attributed the “gaps in the data” to NHS PPUs, rather than independent hospitals. The fact that more than 300 hospitals or PPUs were unable or unwilling to hand over this data highlights the private sector’s continuing lack of transparency, said the Centre for Health and the Public Interest, a social care and health think tank. Read full story Source: The Independent, 2 September 2020 Private Healthcare Information Network press release
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Content Article
Patient Safety Authority: Wrong-site surgery
Patient Safety Learning posted an article in Surgery
Analysis of wrong-site surgery events in Pennsylvania suggests opportunities for prevention. Many steps of preparing the patient for an operation and performing an operation can lead down the path of wrong-site surgery. Preventing wrong-site surgery may require attention at every step of the process. The Patient Safety Authority has provided resources, guidelines and education tools. -
Content ArticleIf a nasogastric tube (NGT) has been misplaced into the respiratory tract and this is not detected before fluids, feed or medication are given, death or severe harm can be caused. The consequences are even more likely to be fatal for patients who are already critically ill. Most nasogastric ‘Never Events’ of feeding into the respiratory tract through a misplaced tube continue to arise from misinterpretation of x-rays by staff who had not been given training in the ‘four criteria’ technique and were unaware that relying on the position of the tube tip alone on a radiograph can be a fatal error. BAPEN has produced this easy reference guide.
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Content ArticleThis report represents the collective work of the National Patient Safety Consortium to identify, for the first time, a list of 15 never events for hospital care in Canada. Never events are patient safety incidents that result in serious patient harm or death and that are preventable using organisational checks and balances. Never events are not intended to reflect judgment, blame or provide a guarantee; rather, they represent a call-to-action to prevent their occurrence. But a list of never events won’t solve anything on its own. For it to have meaning, we need to take deliberate steps to identify when they occur, and harness the knowledge in hospitals across the country to prevent never events from happening. The Canadian Patient Safety Institute (CPSI) encourages a culture of continuous quality improvement — where mistakes are openly reported, disclosure occurs routinely and open discussion and problem solving are encouraged — with patients and families as full and active participants.
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Content ArticleBAPEN would like to draw the attention of those dealing with enteral tube feeding during the COVID-19 crisis to a number of important issues.
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Content Article
Misuse of hydrogen peroxide in a theatre environment
Kathy Nabbie posted an article in Good practice
A tutor once told me that research means 'to search again'. I am always searching or, as someone told me recently, 'sleuthing' for knowledge to improve myself and then share with my colleagues. I would like to share with you my knowledge of hydrogen peroxide. -
News Article
Call for action following latest 'Never Events' report
Patient Safety Learning posted a news article in News
The Association for Perioperative Practice (AfPP) is calling for action to be taken after a recent report suggests little progress has been made to prevent errors within the perioperative environment. The patient safety charity made the call following the release of NHS Improvement’s latest Never Event report; Provisional publication of Never Events reported as occurring between 1 April and 31 December 2019, which revealed an alarming 81% (284) of the never events recorded happened while a patient was on the operating table. Lindsay Keeley, patient safety and quality lead at AfPP said: “The survey highlighted that there’s a need to take action now if we are to support the healthcare profession in reducing the occurrence of never events. It has become clear that receptive team culture, a strong leadership team and better support for staff is what will help to reduce the risk of a never event occurring. It’s vital that those in leadership positions begin to understand the contributory factors in the recurrence of never events and the challenges faced by staff." She went on to highlight some of the recent initiative taking place: “What is promising is that there are practitioners who are developing new, practical and simple solutions every day that can support other team members and can be used within theatres across the country." "One example is Rob Tomlinson’s introduction of the 10,000 Feet initiative – a safety initiative designed to cut through noise and distraction within the theatre environment, particularly at critical points of the patient’s journey. If correctly implemented, initiatives like this can cut through the hierarchies that stop people feeling unable to speak up when they see something that shouldn’t be happening, thus reducing the occurrence of never events" “We of course need to be mindful that there will always be challenges within perioperative practice in the form of interruptions and distractions, but the key is how as practitioners we engage with this to recognise and reduce never events.” Read full story Source: Clinical Services Journal, 25 February 2020 -
Content ArticleThe Association for Perioperative Practice (AfPP) is calling for action to be taken after a recent never events report suggests little progress has been made to prevent errors within the perioperative environment.
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Content ArticleThis report is the Healthcare Safety Investigation Branch (HSIB) first complete investigation which relates to the implantation of the wrong prostheses (artificial body parts) during joint replacement surgery — a surgical never event. A never event is a serious incident that is entirely preventable.
