scholarly journals How can never event data be used to reflect or improve hospital safety performance * ? *

Anaesthesia ◽  
2021 ◽  
Author(s):  
J. Olivarius‐McAllister ◽  
M. Pandit ◽  
A. Sykes ◽  
J. J. Pandit
Keyword(s):  
Safety Performance ◽  
Event Data ◽  
Hospital Safety ◽  
Improve Hospital ◽  
Never Event

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.

Re: Wrong tooth extraction: an examination of ‘Never Event’ data

2017 ◽  
Vol 55 (8) ◽  
pp. 861
Author(s):  
Shofiq Islam ◽  
Uthaya Selbong ◽  
I.W. Ormiston ◽  
J.P. Hayter
Keyword(s):  
Tooth Extraction ◽  
Event Data ◽  
Never Event

Hospital safety index: assessing the readiness and resiliency of hospitals in Indonesia

Facilities ◽  
2019 ◽  
Vol 38 (1/2) ◽  
pp. 39-51 ◽  
Author(s):  
Riza Yosia Sunindijo ◽  
Fatma Lestari ◽  
Oktomi Wijaya
Keyword(s):  
Safety Index ◽  
Content Type ◽  
Hospital Safety ◽  
Intervention Measures ◽  
The Government ◽  
Improve Hospital ◽  
Hospital Readiness ◽  
Role Of The Government ◽  
Practical Implications

Purpose This study aims to assess the hospital readiness and resiliency in a disaster-prone Indonesia. Design/methodology/approach Hospital Safety Index (HSI), containing 151 items, was used to assess ten hospital in West Java and five hospitals in Yogyakarta. Findings The average level of HSI for the hospitals under investigation is B, indicating that their ability to function during and after emergencies and disasters are potentially at risk, thus, intervention measures are needed in the short term. Hospitals in Yogyakarta scored lowly in terms of their emergency and disaster management, even though they have previously experienced major disasters in 2006 and 2010. Practical implications The role of the government is crucial to improve hospital readiness and resiliency in Indonesia. It is recommended that they: identify disaster-prone areas so that their hospital readiness and resiliency can be assessed; assess the readiness and resiliency of hospitals the prioritized areas; implement intervention measures; re-assess the readiness and resiliency of hospitals in the prioritized areas after implementing intervention measures; and develop a framework to ensure that the hospitals can maintain their level of readiness and resiliency over time. Originality/value Research on hospital readiness and resiliency in Indonesia is still limited despite the size of the country and its proneness to disasters. This research has investigated the feasibility and value of using HSI to assess hospital readiness and resilience in Indonesia.

Wrong tooth extraction: an examination of ‘Never Event’ data

2017 ◽  
Vol 55 (2) ◽  
pp. 187-188 ◽  
Author(s):  
M.N. Pemberton ◽  
M.P. Ashley ◽  
A. Saksena ◽  
S. Dickson
Keyword(s):  
Tooth Extraction ◽  
Event Data ◽  
Never Event

scholarly journals Characteristics of and management strategies for 54 suicidal inpatients in a general hospital

2018 ◽  
Vol 5 (2) ◽  
pp. 139-145
Author(s):  
Rong Tan ◽  
De-Ying Hu ◽  
Yan-Hong Han ◽  
Yi-Lan Liu ◽  
Xiao-Ping Ding ◽  
...  
Keyword(s):  
General Hospital ◽  
Reporting System ◽  
Safety Management ◽  
Management Strategies ◽  
Hospital Environment ◽  
Hospital Treatment ◽  
Malignant Neoplasms ◽  
Hospital Safety ◽  
Improve Hospital ◽  
Lethal Means

Abstract Objective The aim of this study was to explore the characteristics of and preventive management strategies for suicidal inpatients in a general hospital. Methods A total of 54 suicide victims were drawn from a patient safety adverse event network reporting system during hospitalization in a general hospital from November 2008 to January 2017. Results Subjects who committed suicide in the general hospital were women and those who suffered from malignant neoplasms during general hospital treatment. Furthermore, most of the patients who committed suicide used more violent suicide methods. The most common and lethal means was jumping from heights at the windowsill. Conclusions It is concluded that management strategies for suicide prevention can be provided from the aspects of patients, medical staff and the hospital environment. It is not only urgent but also feasible to reduce the suicide rate of inpatients and further improve hospital safety management.

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