Search the hub
Showing results for tags 'Never event'.
Found 47 results
-
Content Article
-
Content ArticleHuman factors that could reduce the risk of wrong tooth extraction: Lower team authority gradients - anyone can speak up if concerned irrespective of grade or positionImprove situational awareness - ask the team to confirm the tooth (teeth) to be extractedAvoid miscommunication error: if there is potentially conflicting information (often in relation to molar teeth), seek advice from the prescribing practitioner or another colleague if possibleCheck and double-check radiographs, consent, and clinical examination findingsIf in doubt, do NOT proceed.
-
Content Article
-
Content Article
-
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 is being drafted by 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 organisat -
Content Article
-
Content Article
-
Content Article
Nasogastric tube safety: it’s personal
PatientSafetyLearning Team posted an article in Improving patient safety
-
Content Article
-
Content ArticleKey points include: Misplacement and use of nasogastric feeding tubes leads to ongoing avoidable complications and deaths classified as Never Events despite multiple NHS Alerts since 2005. The most common cause relates to use of X-rays to confirm intragastric placement, followed by poor adherence to guidance on use of gastric aspirate pH, although the vast majority of nasogastric feeding tubes in the UK are passed safely and have their position confirmed using pH checks without issue. The root cause of these problems is a failure by Hospital Trusts and Health Boards to implement gu
-
Content Article
-
Event
Zero harm and never events
Sam posted a calendar 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 -
Content ArticleCase submission When submitting a case, the following information is required. Title (please provide an appropriate title for the case). Patient Description (describe the patient [as much as you would in a case summary] at the time of the event of interest) Nature of Error (the nature of the error and any relevant events or contributing factors) Impacts/Effects (describe the impact of the error on the patient and state whether the patient was harmed or required increased level of care, even if only temporarily) How Error was Recognised (if not noted above, de
-
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 initi -
Content Article
-
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 Ho -
Content ArticleNational guidance for the investigation of any patient safety incidents identified as either a Serious Incident (SI) or No Surprises/Sensitive Issue relating to the provision of digital health care services in Wales
-
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 rep
-
Content ArticleHSIB has made three safety recommendations as a result of this report - two to NHS England and NHS Improvement, and one to the Centre for Perioperative Care. NHS England and NHS Improvement It is recommended that NHS England and NHS Improvement revises the Never Events list to remove events, such as those presented in this national learning report, that do not have strong and systemic safety barriers. It is recommended that NHS England and NHS Improvement develops and commissions programmes of work to find strong and systemic safety barriers for specific incidents where barrie
-
Community PostSubject: 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 deplo
- Posted
- 1 reply
-
-
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. H
-
Content ArticleNasogastric (NG) tubes placed incorrectly, going undetected and delivering food, liquid or medication into the lungs is a well-recognised never event in the NHS. Despite safety alerts and various safety initiatives, the investigation identified that this type of never event continues to happen and that there are not strong ‘systemic’ barriers to prevent NG tubes being accidentally placed into the lungs. Data from national reporting systems shows that there were 14 incidents of misplaced NG tubes from April to September this year. The report acknowledges that measures carried out to tackle
-
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) -
Content Article
Patient Safety Authority: Wrong-site surgery
Patient Safety Learning posted an article in Surgery
-
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 i
