Abstract：
BACKGROUND:Never events (NEs) are serious clinical incidents that cause potentially avoidable harm and impose a significant financial burden on healthcare systems. The purpose of this study was to identify common never events. METHODS:We analysed the NHS England NE data from 2012 to 2020 to identify common never events category and themes. RESULTS:We identified 51 common NE themes in 4 main categories out of a total of 3247 NE reported during this period. Wrong-site surgery was the most common category (n = 1307;40.25%) followed by retained foreign objects (n = 901;27.75%); wrong implant or prosthesis (n = 425;13.09%); and non-surgical/infrequent ones (n = 614; 18.9%). Wrong-side (laterality) and wrong tooth removal were the most common wrong-site NE accounting for 300 (22.95%) and 263 (20.12%) incidents, respectively. There were 197 (15%) wrong-site blocks, 125 (9.56%) wrong procedures, and 96 (7.3%) wrong skin lesions excised. Vaginal swabs were the most commonly retained items (276;30.63%) followed by surgical swabs (164;18.20%) and guidewires (152;16.87%). There were 67 (7.44%) incidents of retained parts of instruments and 48 (5.33%) retained instruments. Wrong intraocular lenses (165; 38.82%) were the most common wrong implants followed by wrong hip prostheses (n = 94; 22.11%) and wrong knees (n = 91; 21.41%). Non-surgical events accounted for 18.9% (n = 614) of the total incidents. Misplaced naso-or oro-gastric tubes (n = 178;29%) and wrong-route administration of medications were the most common events in this category (n = 111;18%), followed by unintentional connection of a patient requiring oxygen to an air flow-meter (n = 93; 15%). CONCLUSION:This paper identifies common NE categories and themes. Awareness of these might help reduce their incidence.
journal_name
World J Surgjournal_title
World journal of surgeryauthors
Omar I,Graham Y,Singhal R,Wilson M,Madhok B,Mahawar KKdoi
10.1007/s00268-020-05867-7subject
Has Abstractpub_date
2021-03-01 00:00:00pages
697-704issue
3eissn
0364-2313issn
1432-2323pii
10.1007/s00268-020-05867-7journal_volume
45pub_type
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journal_title：World journal of surgery
pub_type： 杂志文章,多中心研究
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journal_title：World journal of surgery
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journal_title：World journal of surgery
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pub_type： 杂志文章,评审
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pub_type： 杂志文章
doi：10.1007/s00268-019-05336-w
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pub_type： 杂志文章
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pub_type： 杂志文章
doi：10.1007/s00268-015-3222-2
更新日期：2016-07-01 00:00:00
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pub_type： 临床试验,杂志文章,随机对照试验
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更新日期：2012-10-01 00:00:00
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journal_title：World journal of surgery
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更新日期：2017-11-01 00:00:00
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journal_title：World journal of surgery
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journal_title：World journal of surgery
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更新日期：2014-01-01 00:00:00
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更新日期：2009-12-01 00:00:00
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journal_title：World journal of surgery
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更新日期：2014-07-01 00:00:00
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