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Showing results for tags 'Never event'.
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Content ArticleNatSSIPs2 consists of two inter-related sets of standards: The organisational standards are clear expectations of what Trusts and external bodies should do to support teams to deliver safe invasive care. The sequential standards are the procedural steps that should be taken where appropriate by individuals and teams, for every patient undergoing an invasive procedure. The NatSSIPs2 have evolved to have less emphasis on tick boxes or rare ‘Never Events’ and now include cautions, priorities and a clear concept of proportionate checks based on risk. We recognise that ‘teams’ c
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Content ArticleThe report highlights that, based on analysis of NHS data, there has been a 30% increase in the number of patient safety incidents in surgery – instances that did or could have led to injury or death – since 2015. The analysis also shows that there were 407 ‘Never Events’ in the last year, with no reduction in the number of these incidents since 2015. The report includes results from a survey of 1,500 people who have had surgery in the last five years, with more than three quarters (76%) of the patients surveyed reporting safety concerns during the surgery process. Of those who were worri
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News Article
Record number of 'foreign objects' left inside patients after surgical blunders
Patient Safety Learning posted a news article in News
A record number of "foreign objects" have been left inside patients' bodies after surgery, new data reveals. Incidents analysed by the PA news agency showed it happened a total of 291 times in 2021/22. Swabs and gauzes used during surgery or a procedure are one of the most common items left inside a patient, but surgical tools such as scalpels and drill bits have been found in some rare cases. A woman from east London described how she "lost hope" after part of a surgical blade was left inside her following an operation to remove her ovaries in 2016. The 49-year-old, who sp -
News Article
Midlands hospital investigating forceps left inside patient after surgery
Patient Safety Learning posted a news article in News
A hospital is investigating how a pair of metal surgical forceps were left inside a patient after they had been stitched up after abdominal surgery. Worcestershire Acute Hospitals NHS trust has apologised unreservedly and said the incident at Redditch’s Alexandra hospital was “exceptionally rare”. The medical blunder only became apparent after a seven-hour abdominal procedure last month, according to BBC Midlands, when the forceps were reported to be missing. The worst fears of medics were confirmed when the missing 15cm arterial clamp was found by an X-ray while the patient was -
Event
Learning from Never Events
Patient Safety Learning posted a calendar event in Community Calendar
Never events are defined as “serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations.” They are designed to act as a red flag for improvement by NHS organisations. This one day masterclass will focus on safety culture around Never Events within healthcare organisations. There were 364 never events in 2020/21 and 349 between April 2021 and Jan 2022. The masterclass will look at how Never Events have been investigated and at Human Factors approaches to improving learning an -
Content ArticleDelphi study participants Participants were from the seven regions identified by NHS England. The study revisited several questions from round one to gather further knowledge and understanding of the responses received. The debrief was not undertaken due to all team members not being present, staff wanting to go home, current culture and list overruns. Key initial findings of Delphi study round two The second round facilitated a broader engagement in the literature, as well highlighting a number of reasons why full compliance has not yet been universally achieved. The Delphi study
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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". -
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 -
News ArticleHundreds of patients with metallic implants narrowly avoided death or serious injury after being wrongly referred for MRI scans, an investigation revealed yesterday. The powerful magnets used in the machines can displace and damage metallic items such as pacemakers, ear implants and aneurysm clips. Doctors should question patients and check medical records before requesting a scan because of the risk of injury. But hospitals in England recorded 315 near-misses from April 2020 to March 2022 involving patients sent for an MRI. An MRI scan at Mid Yorkshire Hospitals Trust was ditch
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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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Content Article
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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Content Article
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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News Article
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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News Article
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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Content Article
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: -
Content Article
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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