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Showing results for tags 'Never event'.
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News ArticleSurgical blunders have soared 60% in five years – and extreme mistakes are now a daily occurrence in the NHS. Some 13,921 people were treated for damage caused by botched operations in the year to March 31 – up from 8,695 in England in 2016/17. Cases involved an “unintentional cut, puncture, perforation or haemorrhage”. Separately, a report from NHS England shows 134 patients fell victim to so-called Never Events from April 1 to July 31. Extreme errors included two women left infertile after their ovaries were wrongly removed. Injections and invasive tests were given to the
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The World Health Organization (WHO) introduced the surgical safety checklist in 2009 after a successful trial in eight pilot countries; the term ‘Never Event’ has been in existence since 2001.[1] NHS England defines a Never Event as; “Serious incidents that are entirely preventable because guidance of safety recommendations providing strong systematic barriers are available at a national level and should have been implemented by all healthcare providers.” The current list of Never Events still only classes three reportable intra-operative ‘Never Events’: wrong site surgery, wrong imp- Posted
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Research shows that poor handover in hospitals puts patients at risk of severe harm
Anonymous posted an article in Handover
Handover in hospitals is the cause of frequent and severe harm to patients, according to new research* by digital health platform, CAREFUL. Many patients are suffering because handover is poorly controlled and under-recognised as a source of clinical risk. Handover is the transfer of responsibility and crucial patient information between practitioners and teams. Handover takes place when shifts change and when patients are transferred between departments or outside of the hospital into another care setting. This is a time when staff are under pressure and when mistakes can happen – as the -
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Major trust records fifth never event at troubled department
Patient Safety Learning posted a news article in News
A fifth patient has been given the wrong blood at a major teaching hospital’s haematology department where patient safety concerns were raised by clinicians last year. The incident, at University Hospitals Birmingham Foundation Trust, is the fifth never event involving patients being transfused with the wrong blood at the trust since April 2020. Only 15 such never events have been recorded in England in the last two financial years, which means UHB accounted for a third of the total in 2020-21 and 2021-22. HSJ revealed last year that several clinicians had raised safety concerns -
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Wrong surgery and jabs among hundreds of NHS ‘never events’
Patient Safety Learning posted a news article in News
A woman who had her ovaries removed by mistake was one victim of the hundreds of “never events” that occurred in the NHS over the past year. Between April 2021 and March 2022 more than 400 patients in England’s hospitals suffered errors so serious that they should never have happened according to data released by NHS England. They include the wrong hips, legs, eyes and knees being operated on, and diabetic patients being given too much insulin. Foreign objects were left inside 98 patients after operations, including gauzes, swabs, drill guides, scalpel blades and needles. Vaginal swa -
Content ArticleNever Events 1 April 2021 – 31 March 2022 by type of incident: Wrong site surgery – 171 Retained foreign object post procedure – 98 Wrong implant/prosthesis – 47 Misplaced naso or oro gastric tubes and feed administered – 31 Administration of medication by the wrong route – 21 Unintentional connection of a patient requiring oxygen to an air flowmeter – 13 Overdose of insulin due to abbreviations or incorrect device – 11 Transfusion or transplantation of ABO incompatible blood components or organs – 7 Falls from poorly restricted windows –
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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 discu
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Surgical fires must become 'Never Events' (July 2020)
Patient Safety Learning posted an article in Surgery
The fire triangle below sets out the three elements that must be present for a surgical fire to occur within the operating theatre: -
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Prevention of Future Deaths report – Van Tuyen (22 February 2022)
Mark Hughes posted an article in Coroner reports
In his report, the Coroner lists the following matters of concern: Using a misplaced nasogastric tube is recognised as a 'never event', namely an event which is wholly preventable and should never happen. The court heard evidence at the inquest that an NHS improvement patient safety alert issued in 2016 identified that between 2011-2016 there had been 95 incidents of misplaced nasogastric tubes used to administer fluids or medication, 32 of which resulted in death. The court heard that Barts NHS Trust had at least seven incidents relating to misplaced nasogastric tube since- Posted
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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,
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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
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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 -
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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 -
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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
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Misuse of hydrogen peroxide in a theatre environment
Kathy Nabbie posted an article in Good practice
During my many years of working in operating theatres, I observed that hydrogen peroxide was adopted by surgeons as a ritual for washing out wounds and deep cavities. An entire bottle of 200 ml hydrogen peroxide was mixed with 200 ml of normal saline. It seems this ritual was passed down from consultant to trainee and it then became a habit. In a recent post on the hub, I mentioned that women in 1920 were given Lysol as a disinfectant to preserve their feminity and maritial bliss! Lysol contains hydrogen peroxide, so women were daily irrigating their vaginas with a harmful solution -
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