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Identification of Common Themes from Never Events Data Published by NHS England.

Islam Omar1, Yitka Graham1,2, Rishi Singhal3

  • 1Bariatric Unit, Department of General Surgery, Sunderland Royal Hospital, South Tyneside and Sunderland NHS Trust, Sunderland, SR4 7TP, UK.

World Journal of Surgery
|November 20, 2020
PubMed
Summary

Never events (NEs) are serious clinical incidents that cause avoidable harm. This study identified 51 common NE themes, with wrong-site surgery and retained foreign objects being the most frequent, to help reduce their occurrence.

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Area of Science:

  • Healthcare quality and patient safety
  • Clinical risk management
  • Medical error analysis

Background:

  • Never events (NEs) represent serious clinical incidents with potentially avoidable harm and significant financial implications for healthcare systems.
  • Understanding the common types of NEs is crucial for developing targeted prevention strategies.

Purpose of the Study:

  • To identify and categorize common never events (NEs) reported in the NHS England.
  • To analyze the frequency and themes of NEs to inform patient safety initiatives.

Main Methods:

  • Analysis of NHS England Never Events (NE) data from 2012 to 2020.
  • Categorization and thematic analysis of reported NEs to identify common patterns.

Main Results:

  • A total of 3247 NEs were reported, with 51 common themes identified across 4 main categories.
  • Wrong-site surgery (40.25%) and retained foreign objects (27.75%) were the most prevalent NE categories.
  • Specific common NEs include wrong-side surgery, retained vaginal/surgical swabs, wrong intraocular lenses, and misplaced nasogastric tubes.

Conclusions:

  • This study successfully identified prevalent categories and themes of never events (NEs).
  • Increased awareness of these common NEs can contribute to reducing their incidence in clinical practice.