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Never Events
Published in Paul Bowie, Carl de Wet, Aneez Esmail, Philip Cachia, Safety and Improvement in Primary Care: The Essential Guide, 2020
Carl de Wet, Catherine O’Donnell, Paul Bowie
The current definition of a Never Event is ‘a serious, largely preventable patient safety incident that should not occur if the available preventable measures were implemented by healthcare workers’.1 An unambiguous example of a Never Event in the acute hospital context is performing a surgical procedure on the wrong limb. Therefore, the rationale for devising and implementing lists of Never Events in healthcare is to mitigate or eliminate the risks associated with these types of serious but preventable occurrences.
Critical Incidents
Published in Elizabeth Combeer, The Final FRCA Short Answer Questions, 2019
Never events are serious incidents that are entirely preventable because guidance or safety recommendations providing strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers.
Human factors, patient safety and quality improvement
Published in Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie, Bailey & Love's Short Practice of Surgery, 2018
Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie
One subset of serious incidents is a Never or Serious Reportable Event. These events are wholly preventable; for example, a retained abdominal swab or instrument, where guidance providing strong systemic protective barriers should have been implemented, namely checklists. Each Never Event type has the potential to cause serious patient harm or death. However, serious harm or death is not required to have occurred for that incident to be categorised as a Never or Serious Reportable Event.
Overlooked guide wire: a multicomplicated Swiss Cheese Model example. Analysis of a case and review of the literature
Published in Acta Clinica Belgica, 2020
Henri Thonon, Florence Espeel, Ficart Frederic, Frédéric Thys
The most used technique to place a CVC is the Seldinger technique. It involves the use of a guide wire that can be forgotten in the patient central vessel. This omission can be called a never event, a serious but preventable error in medical care that should never occur if healthcare workers implemented the relevant preventive measures [19]. A recent analysis of published case reports made by Pokharel and colleagues found 76 described cases [7]. The occurrence of this complication is probably underestimated because all cases are not systematically reported. In most cases (75%), the patients remain asymptomatic. In the symptomatic quarter of patients, some present short-term complications (retroperitoneal haematoma, gall bladder perforation and thrombosis) and other delayed complications (ventricular perforation, cardiac tamponade, palpitation, PE, endocarditis and sepsis).
Is surgery on the right track? The burden of wrong-site surgery
Published in Baylor University Medical Center Proceedings, 2023
Ahsan Zil-E-Ali, Lily Laubscher, Islam Kourampi, Christos Tsagkaris
As these never events occur, they also add a large economic burden on healthcare systems. These surgical never events are costly and add a significant problem that can challenge the sustainability of surgical services. According to a review of medical liability settlements and judgments in the National Practitioner Data Bank, a total of $1.3 billion was recorded in payouts for surgical never events for two decades (1990–2010). Wrong-procedure events were linked to the greatest median payment. According to this data bank, in a span of 20 years, the United States had 2447 wrong procedures, 2413 WSS, and 27 wrong-patient surgeries.5
Identifiable risk factors for thirty-day complications following arthroscopic rotator cuff repair
Published in The Physician and Sportsmedicine, 2018
Jessica H. Heyer, Xiangyu Kuang, Richard L. Amdur, Rajeev Pandarinath
As the healthcare system continues to evolve, certain ‘never events,’ defined as medical errors or complications are so egregious that they should never occur, can result in large financial penalties for both the physician as well as the hospital. Being able to preoperatively identify patients who are at a higher risk for postoperative complications can allow for better stratification of risk, which can help surgeons operating on high-risk patients to justify higher complication rates with healthcare payors.