scholarly journals Deaths by horsekick in the Prussian army - and other ‘Never Events’ in large organisations

Anaesthesia ◽  
2015 ◽  
Vol 71 (1) ◽  
pp. 7-11 ◽  
Author(s):  
J. J. Pandit
Keyword(s):  
Never Events

Expert Advises on Avoiding ‘Never Events’

2009 ◽  
Vol 10 (6) ◽  
pp. 15
Author(s):  
HEIDI SPLETE
Keyword(s):  
Never Events

Common general surgical never events: analysis of NHS England never event data

2021 ◽  
Vol 33 (1) ◽  
Author(s):  
Islam Omar ◽  
Rishi Singhal ◽  
Michael Wilson ◽  
Chetan Parmar ◽  
Omar Khan ◽  
...  
Keyword(s):  
Breast Implants ◽  
Skin Condition ◽  
Chest Drain ◽  
Event Data ◽  
Wrong Site Surgery ◽  
Wrong Side ◽  
Retained Foreign Body ◽  
Never Events ◽  
Never Event ◽  
Wrong Site

Abstract Background There is little available data on common general surgical never events (NEs). Lack of this information may have affected our attempts to reduce the incidence of these potentially serious clinical incidents. Objectives The purpose of this study was to identify common general surgical NEs from the data held by the National Health Service (NHS) England. Methods We analysed the NHS England NE data from April 2012 to February 2020 to identify common general surgical NEs. Results There was a total of 797 general surgical NEs identified under three main categories such as wrong-site surgery (n = 427; 53.58%), retained items post-procedure (n = 355; 44.54%) and wrong implant/prosthesis (n = 15; 1.88%). We identified a total of 56 common general surgical themes—25 each in the wrong-site surgery and retained foreign body categories and six in wrong implants category. Wrong skin condition surgery was the commonest wrong-site surgery (n = 117; 27.4%). There were 18 wrong-side chest drains (4.2%) and 18 (4.2%) wrong-side angioplasty/angiograms. There were seven (1.6%) instances of confusion in pilonidal/perianal/perineal surgeries and six (1.4%) instances of biopsy of the cervix rather than the colon or rectum. Retained surgical swabs were the most common retained items (n = 165; 46.5%). There were 28 (7.9%) laparoscopic retrieval bags with or without the specimen, 26 (7.3%) chest drain guide wires, 26 (7.3%) surgical needles and 9 (2.5%) surgical drains. Wrong stents were the most common (n = 9; 60%) wrong implants followed by wrong breast implants (n = 2; 13.3%). Conclusion This study found 56 common general surgical NEs. This information is not available to surgeons around the world. Increased awareness of these common themes of NEs may allow for the adoption of more effective and specific safeguards and ultimately help reduce their incidence.

The never-ending story of Never Events in the NHS

2021 ◽  
Vol 30 (13) ◽  
pp. 826-827
Author(s):  
John Tingle
Keyword(s):  
Law School ◽  
Never Events

John Tingle, Lecturer in Law, Birmingham Law School, University of Birmingham, discusses several recent publications on Never Events in the NHS

scholarly journals Never events: Patient safety definitions

BDJ ◽  
2018 ◽  
Vol 225 (9) ◽  
pp. 795-796
Author(s):  
E. Ensaldo-Carrasco ◽  
A. Carson-Stevens ◽  
K. Cresswell ◽  
R. Bedi ◽  
A. Sheikh
Keyword(s):  
Patient Safety ◽  
Never Events

Mise en œuvre de listes de contrôle « never events » dans le système d’information en radiothérapie

2017 ◽  
Vol 21 (6-7) ◽  
pp. 665-669
Author(s):  
G. Brusadin ◽  
M.S. Bour ◽  
E. Deutsch ◽  
N. Kouchit ◽  
S. Corbin ◽  
...  
Keyword(s):  
Mise En Œuvre ◽  
Système D’Information ◽  
Never Events

scholarly journals National trends, estimated costs, and predictors of ‘never events’ following birth hospitalization

2022 ◽  
Vol 226 (1) ◽  
pp. S602
Author(s):  
Timothy Wen ◽  
Chiara Corbetta-Rastelli ◽  
Nasim C. Sobhani ◽  
Brian Liu ◽  
Brittany Arditi ◽  
...  
Keyword(s):  
Never Events ◽  
National Trends ◽  
Birth Hospitalization
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