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Showing results for tags 'Never event'.
Found 110 results
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Content ArticleIn this article, John Tingle, Assistant Professor at the University of Birmingham Law School, discusses recent developments in patient safety in the context of possible reform of the clinical negligence system in the UK.
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Content ArticleIn this blog, the Healthcare Safety Investigation Branch (HSIB) reflects on the recent publication of the new National Safety Standards for Invasive Procedures (NatSSIPs 2) by the Centre for Perioperative Care. It outlines how these standards can help NHS organisations provide safer care and reduce the number of patient safety incidents, including a comment on this from Deinniol Owens, Associate Director of National Investigations at HSIB.
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Content ArticleThe original National Safety Standards for Invasive Procedures (NatSSIPs) were published in 2015. Understanding of how to deliver safe care in a complex and pressurised system is evolving. These revised standards (NatSSIPs2) are intended to share the learning and best practice to support multidisciplinary teams and organisations to deliver safer care. The Centre for Perioperative Care shares their slideset on the revised standards.
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Content ArticleThe Centre for Perioperative Care (CPOC) has published new safety standards (NatSSIPs2) to enable all hospitals in the UK to improve patient safety by applying a consistent and proportionate set of safety checks for all invasive procedures. Listen to the podcast from the Royal College of Anaesthetists on the new standards.
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News Article
Swab 'left inside patient for months after surgery'
Patient Safety Learning posted a news article in News
A consultant urologist left a 6.5cm swab in a patient after surgery and failed to identify it in a scan three months later, an inquiry has heard. The public inquiry concerns the work of Aidan O'Brien at the Southern Trust between January 2019 and June 2020. It heard Mr O'Brien endangered or potentially endangered lives by failing to review medical scans. He previously claimed the trust provided an "unsafe" service and was trying to shift blame on to its medics. On Tuesday, the inquiry into Mr O'Brien's clinical practice heard almost 600 patients received "suboptimal care". Counsel for the inquiry Martin Wolfe KC said the 6.5cm swab was left inside a patient by Mr O'Brien during a bladder tumour operation in July 2009. The error was described as a "never event'. At a CT scan appointment three months later in October 2009, a mass inside the patient's body was discovered by the reporting consultant radiologist. While he did not say it was a swab, he did "highlight the abnormality", said Mr Wolfe. A report was sent to Mr O'Brien but, the Inquiry heard, he did not read it and no one took steps to check out the abnormality. Read full story Source: BBC News, 9 November 2022 -
News Article
‘Squashed’ breathing tube may have caused teenager’s death, inquest hears
Patient Safety Learning posted a news article in News
A teenager died after a breathing tube was possibly squashed by a wheel of her hospital trolley during emergency surgery, an inquest has heard. Jasmine Hill, 19, had a cardiac arrest shortly after undergoing a procedure on her neck at Gloucestershire royal hospital in Gloucester. The inquest heard that a report commissioned by lawyers acting for Hill’s family referred to the tube being “squashed by the wheel of a trolley”. Hill, from Cirencester, had been readmitted to the hospital after her neck became swollen five days after a thyroidectomy – the removal of all or part of the thyroid gland – in September 2020. Doctors thought the site of the surgery in Hill’s neck, which was red and swollen, may have become infected and it was decided the wound should be cleaned under general anaesthetic. The procedure took less than an hour and the teenager went into cardiac arrest shortly after she was moved by staff from the operating table to a bed. Gloucestershire coroner’s court heard an endotracheal tube, which supports breathing, was positioned behind Hill’s head and away from her neck, fixed to a holder and connected to the ventilator. The assistant Gloucestershire coroner Roland Wooderson asked Dr Hiro Ishii, who carried out the procedure, whether he was aware that the anaesthetist had checked the position of the endotracheal tube. Ishii replied: “I didn’t make a formal inquiry at that stage.” Read full story Source: The Guardian, 7 November 2022 -
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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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 -
News Article
Hundreds of serious incidents recorded at struggling small trust
Patient Safety Learning posted a news article in News
One of the country’s smallest trusts recorded 277 serious incidents over a two-year period, HSJ can reveal. Delays in treatment, missed diagnoses, adverse media coverage and “suboptimal” care were among the hundreds of serious incidents reported at the struggling Isle of Wight Trust from the start of 2018 and up to November 2019. There were also two never events in 2019 — a “wrong site” surgery and an incident in which a patient was mistakenly connected to an air flow meter, rather than an oxygen supply. The trust said the level of incidents did not neccessarily reflect poor care, and did not mean patients had come to harm. The trust was placed in special measures in April 2017 after it was rated “inadequate” by the Care Quality Commission due to “significant” concerns over patient safety. It was upgraded to “requires improvement” in September 2019, but remains in special measures. Read full story (paywalled) Source: HSJ, 22 January 2020 -
News Article
India: When a ‘never event’ hits a patient
Patient Safety Learning posted a news article in News
A young woman was left with a retained foreign object, after surgery in an India hospital. A checklist could have avoided her death. The response from the health officials was: “We have issued a show-cause notice to the staff seeking an explanation. We will initiate departmental action based on their replies and finding of our inquiry.” In the fields of healthcare quality and patient safety, such punitive measures of “naming and shaming” have not worked. T.S. Ravikumar, President, AIIMS Mangalagiri, Andhra Pradesh, moved back to India eight years ago with the key motive to improve accountability and safety in healthcare delivery. He believes that we have a long way to go in reducing “preventable harm” in hospitals and the health system in general. "We need to move away from fixing blame, to creating a 'blame-free culture' in healthcare, yet, with accountability. This requires both systems design for safe care and human factors engineering for slips and violations". "Providing safe care without harm is a 'team sport', and we need to work as teams and not in silos, with mutual respect and ability to speak up where we observe any deviation or non-compliance with rules, says Ravikumar. Basic quality tools and root-cause analysis for adverse events must become routine. Weekly mortality/morbidity conferences are routine in many countries, but not a routine learning tool in India. He proposes acceleration of the recent initiative of the DGHS of the Government of India to implement a National Patient Safety Framework, and set up an analytical “never events” or sentinel events reporting structure. Read full story Source: The Hindu, 12 January 2020 -
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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Content Article
Prevention of Future Deaths report – Van Tuyen (22 February 2022)
Mark Hughes posted an article in Coroner reports
Van Thai Tuyen was admitted to the Royal London Hospital on 1 August 2021 for treatment of a stroke. A nasogastric tube was inserted to administer medication and food, due to Mr Tuyen being assessed as having an unsafe swallow. Despite an x-ray showing that the nasogastric tube had been misplaced into his right lung the tube was used to administer approximately 300ml of liquid feed. This caused the cavitating necrotising pneumonia from which he died.- Posted
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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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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 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 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 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 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.
