ArticleWorld journal of surgery2021
Identification of Common Themes from Never Events Data Published by NHS England.
Article in World journal of surgery, 2021. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 8 papers, 2 of them syntheses that pooled it.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
8 citing papers in PubMed, 2 syntheses or guidelines pooled it.
- Identifying a list of healthcare 'never events' to effect system change: a systematic review and narrative synthesis.BMJ open quality · 2023Pooled it
- Interventions to reduce the incidence of medical error and its financial burden in health care systems: A systematic review of systematic reviews.Frontiers in medicine · 2022Pooled it
- Embedding into the ways of working in the NHS: A seamless transition and reflective learning as a clinical observer in general internal medicine.Future healthcare journal · 2025Article
- Article
- Root causes and preventability of unintentionally retained foreign objects after surgery: a national expert survey from Switzerland.Patient safety in surgery · 2023Article
- Safety considerations in laparoscopic surgery: A narrative review.World journal of gastrointestinal endoscopy · 2022Review
- Analysis of National Bariatric Surgery Related Clinical Incidents: Lessons Learned and a Proposed Safety Checklist for Bariatric Surgery.Obesity surgery · 2021Article
- Engaging perioperative students in online learning: Human factors.Journal of perioperative practiceArticle
Corrections and comments
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Authors and funding
6 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundNever 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.
methodsWe analysed the NHS England NE data from 2012 to 2020 to identify common never events category and themes.
resultsWe 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%).
conclusionThis paper identifies common NE categories and themes. Awareness of these might help reduce their incidence.
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