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Showing results for tags 'Never event'.
Found 110 results
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Content ArticlePatient safety groups consider surgical fires “never events,” incidents that can be avoided entirely with organisational checks and balances. Yet, the Canadian Medical Protective Association (CMPA) has handled dozens of lawsuits and regulatory complaints involving surgical burns in recent years. According to a review of 54 cases of perioperative burns between 2012 and 2016, almost a third involved surgical fires, while the rest involved burns from surgical equipment and chemicals used in surgery. Many patients were left scarred, disfigured and psychologically traumatised. Fifteen percent were severely harmed, with airway damage or full-thickness burns destroying the sensory nerves and all layers of the skin.
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Content ArticleWomen can be left in severe pain and at risk of infection if swabs and tampons used after childbirth are accidentally left in the vagina. That’s the safety risk the Healthcare Safety Investigation Branch (HSIB) highlights in this report.
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Content ArticleThis Care Quality Commission (CQC) report focuses on why avoidable harm remains a persistent problem within healthcare.
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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 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. -
Content ArticleThe Never Events policy and framework sets out the NHS’s policy on Never Events. It explains what they are and how staff providing and commissioning NHS-funded services should identify, investigate and manage the response to them. It is relevant to all NHS-funded care.
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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.
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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 ArticleA Human Factors approach to significant event analysis for more meaningful improvement implementation to minimise the risks of the event happening again. Enhanced SEA is a National Education Scotland innovation (funded by the Health Foundation 2012 SHINE programme) which aims to guide health care teams to apply human factors thinking when performing a significant event analysis, particularly where the event has had an emotional impact on staff involved. Taking this approach will help individual clinicians and care teams to openly, honestly and objectively analyse patient safety incidents, particularly more difficult or sensitive safety cases, by ‘depersonalising’ the incident and searching for deeper, systems-based reasons for why the significant event happened.
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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.
