Identification of common themes from never events data published by NHS England. | PSNet

Provide Feedback |

Submit a Case

Register

Study

Identification of common themes from never events data published by NHS England.

April 14, 2021

Omar I, Graham Y, Singhal R, et al. World J Surg. 2021;45(3):697-704.

View more articles from the same authors.

Never events can result in serious patient harm and indicate serious underlying organizational safety problems. This study analyzed never events occurring between 2012 and 2020 in the National Health Services and categorized 51 common never events into four categories – wrong site surgery (40% of events); retained foreign objects post-procedure (28%); wrong implant/prosthesis (13%); and non-surgical/infrequent never events (19%). Awareness of these themes may support focused efforts to reduce their incidence and development of specific local safety standards.

PubMed citation

Related web site

Related Resources From the Same Author(s)

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

April 7, 2021

Preventable morbidity and mortality among non-trauma emergency surgery patients: the role of personal performance and system flaws in adverse events.

May 12, 2021

We asked the experts: the WHO Surgical Safety Checklist and the COVID-19 pandemic: recommendations for content and implementation adaptations.

March 17, 2021

Hospital acquired infections in surgical patients: impact of COVID-19-related infection prevention measures.

April 20, 2022

Standardise, Educate, Harmonise: Commissioning the Conditions for Safer Surgery.

April 23, 2014

Avoiding a second wave of medical errors: the importance of human factors in the context of a pandemic.

August 26, 2020

NHS Improvement.

May 18, 2019

Repurposing clinical decision support system data to measure dosing errors and clinician-level quality of care.

November 11, 2020

Clarifying radiology's role in safety events: a 5-year retrospective common cause analysis of safety events at a pediatric hospital.

September 2, 2020

From principles to practice: embedding clinical reasoning as a longitudinal curriculum theme in a medical school programme.

June 15, 2022

Digital Clinical Safety Strategy

October 20, 2021

Variability in collection and use of race/ethnicity and language data in 93 pediatric hospitals.

October 14, 2020

Prevalence, nature, severity and preventability of adverse drug events in mental health settings: findings from the MedicAtion relateD harm in mEntal health hospitals (MADE) study.

August 11, 2021

Non-technical skills in surgery during the COVID-19 pandemic: an observational study.

March 9, 2022

Central venous catheter guidewire retention: lessons from England's never event database.

May 4, 2022

Barriers to accessing nighttime supervisors: a national survey of internal medicine residents.

March 17, 2021

Advancing diagnostic safety research: results of a systematic research priority setting exercise.

February 24, 2021

To expand the evidence base about harms from tests and treatments.

September 15, 2021

A Promise to Learn—a Commitment to Act: Improving the Safety of Patients in England.

August 21, 2013

Independent Mortality Review of Cardiac Surgery at St George’s University Hospitals NHS Foundation Trust.

April 15, 2020

Performance variability in perioperative sentinel events: report on a nationwide data set.

April 20, 2022

Care coordination strategies and barriers during medication safety incidents: a qualitative, cognitive task analysis.

March 10, 2021

Strategies to reduce errors associated with 2-component vaccines.

December 2, 2020

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

May 19, 2021

Patient and physician perspectives of deprescribing potentially inappropriate medications in older adults with a history of falls: a qualitative study.

May 5, 2021

Transparency, public reporting, and a culture of change to quality and safety in cardiac surgery.

November 9, 2022

The July Effect in podiatric medicine and surgery residency.

July 14, 2021

How to induce an error management climate: experimental evidence from newly formed teams.

November 2, 2022

Health care providers’ negative implicit attitudes and stereotypes of American Indians.

March 31, 2021

Patient harm from cardiovascular medications.

August 25, 2021

Post-discharge adverse events among African American and Caucasian patients of an urban community hospital.

July 15, 2020

Diagnostic discrepancies between antemortem clinical diagnosis and autopsy findings in pediatric cancer patients.

September 22, 2021

Direct oral anticoagulant-related medication incidents and pharmacists' interventions in hospital in-patients: evaluation using Reason's accident causation theory.

December 22, 2021

Dual surgeon operating to improve patient safety.

September 29, 2021

Influence of opioid prescription policy on overdoses and related adverse effects in a primary care population.

May 19, 2021

Ethical challenges in child abuse: what is the harm of a misdiagnosis?

June 9, 2021

Medication incident recovery and prevention utilising an Australian community pharmacy incident reporting system: the QUMwatch study.

May 5, 2021

Clinical diagnoses vs. autopsy findings in early deceased septic patients in the intensive care: a retrospective cohort study.

July 28, 2021

The efficacy of mindful practice in improving diagnosis in healthcare: a systematic review and evidence synthesis.

October 13, 2021

Work effort, readability and quality of pharmacy transcription of patient directions from electronic prescriptions: a retrospective observational cohort analysis.

March 31, 2021

Classification of opioid dependence, abuse, or overdose in opioid-naive patients as a "Never Event".

August 5, 2020

Evaluation of feedback modalities and preferences regarding feedback on decision-making in a pediatric emergency department.

July 6, 2022

Crisis management for surgical teams and their leaders, lessons from the COVID-19 pandemic; a structured approach to developing resilience or natural organisational responses.

September 15, 2021

Supporting recovery after adverse events: an essential component of surgeon well-being.

February 10, 2021

Automated identification of diagnostic labelling errors in medicine.

June 8, 2022

Deprescribing for community-dwelling older adults: a systematic review and meta-analysis.

September 16, 2020

Increased patient safety-related incidents following the transition into Daylight Savings Time.

September 9, 2020

When bad things happen: training medical students to anticipate the aftermath of medical errors.

September 2, 2020

Association between surgeon technical skills and patient outcomes.

September 9, 2020

Human-based errors involving smart infusion pumps: a catalog of error types and prevention strategies.

September 9, 2020

Incidence and OR team awareness of “near-miss” and retained surgical sharps: a national survey on United States operating rooms.

June 23, 2021

Improving the approach to defining, classifying, reporting and monitoring adverse events in seriously ill older adults: recommendations from a multi-stakeholder convening.

June 15, 2022

Barriers and facilitators to patient engagement in patient safety from patients and healthcare professionals' perspectives: a systematic review and meta-synthesis.

August 25, 2021

Ethical considerations and patient safety concerns for cancelling non-urgent surgeries during the COVID-19 pandemic: a review.

May 12, 2021

Clinical characteristics and short-term outcomes of acute kidney injury missed diagnosis in older patients with severe COVID-19 in intensive care unit.

May 19, 2021

Impact of computerised physician order entry (CPOE) on the incidence of chemotherapy-related medication errors: a systematic review.

April 7, 2021

Association of surgeon-patient sex concordance with postoperative outcomes,

December 22, 2021

2020 Pennsylvania Patient Safety Reporting: an analysis of serious events and incidents from the nation’s largest event reporting database.

May 19, 2021

Impact of pharmacist interventions on medication errors in hospitalized pediatric patients: a systematic review and meta-analysis.

October 14, 2020

Opioid guidelines for common dental surgical procedures: a multidisciplinary panel consensus.

March 25, 2020

Association of anesthesiologist staffing ratio with surgical patient morbidity and mortality.

August 3, 2022

Remember that patient you saw last week: characteristics and frequency of patients experiencing anticipated and unanticipated death following ED discharge.

December 1, 2021

Direct oral anticoagulants: a review of common medication errors.

November 21, 2018

Recognition of adverse drug events in older hospitalized medical patients.

July 11, 2012

COVID-19 increased the risk of ICU-acquired bloodstream infections: a case-cohort study from the multicentric OUTCOMEREA network.

March 17, 2021

Errors in adult trauma resuscitation: a systematic review.

June 30, 2021

Understanding preventable deaths in the geriatric trauma population: analysis of 3,452,339 patients from the Center of Medicare and Medicaid Services Database.

December 1, 2021

Risk reduction strategy to decrease incidence of retained surgical items.

August 31, 2022

Relationships between pediatric safety indicators across a national sample of pediatric hospitals: dispelling the myth of the "safest" hospital.

June 22, 2022

Adverse events and burnout: the moderating effects of workgroup identification and safety climate.

July 1, 2020

Patient and hospital characteristics associated with delayed diagnosis of appendicitis.

February 1, 2023

Does increased schedule flexibility lead to change? A national survey of program directors on 2017 work hours requirements.

September 23, 2020

Analysis of iatrogenic and in-hospital medication errors reported to United States poison centers: a retrospective observational study.

June 24, 2020

Developing and aligning a safety event taxonomy for inpatient psychiatry.

July 13, 2022

Comparison of methods to reduce bias from clinical prediction models of postpartum depression.

May 12, 2021

The second victim of unanticipated adverse events.

December 14, 2022

Raising and Responding to Concerns.

February 25, 2015

Adverse health events related to self-medication practices among elderly: a systematic review.

May 31, 2017

Error reduction in trauma care: lessons from an anonymized, national, multicenter mortality reporting system.

March 23, 2022

Accuracy in patient understanding of common medical phrases.

December 21, 2022

Scoping review of studies evaluating frailty and its association with medication harm.

June 22, 2022

Outcomes and patient safety in overlapping vs. nonoverlapping total joint arthroplasty: a systematic review and meta-analysis.

January 19, 2022

Association between operative autonomy of surgical residents and patient outcomes.

March 23, 2022

Safety events impacting hospitalized patients following motor vehicle crashes: a qualitative study of reports from Pennsylvania hospitals.

October 6, 2021

Patient Safety Incident Response Framework.

August 31, 2022

Correlation between the number of patient-reported adverse events, adverse drug events, and quality of life in older patients: an observational study.

November 2, 2022

State medical board regulation of compounding in physician offices.

June 9, 2021

LeDeR - Learning from Lives and Deaths.

January 19, 2022

Patient safety trends in 2021: an analysis of 288,882 serious events and incidents from the nation’s largest event reporting database.

July 6, 2022

Changes in hospital-acquired conditions and mortality associated with the hospital-acquired condition reduction program.

September 29, 2021

Hospitalizations and deaths related to adverse drug events worldwide: systematic review of studies with national coverage.

May 25, 2022

Patient harm resulting from medication reconciliation process failures: a study of serious events reported by Pennsylvania hospitals.

March 24, 2021

Interprofessional clinical event debriefing-does it make a difference? Attitudes of emergency department care providers to INFO clinical event debriefings.

December 7, 2022

Surgical teams' attitudes about surgical safety and the surgical safety checklist at 10 years: a multinational survey.

November 17, 2021

Evaluation of postoperative handover using a tool to assess information transfer and teamwork.

May 4, 2011

Has the pendulum swung too far?; The impact of missed abdominal injuries in the era of nonoperative management.

September 16, 2009

Association of coworker reports about unprofessional behavior by surgeons with surgical complications in their patients.

July 10, 2019

Preventable morbidity at a mature trauma center.

June 24, 2009

Diagnostic discordance, health information exchange, and inter-hospital transfer outcomes: a population study.

June 20, 2018

Prevalence and nature of medication errors and medication-related harm following discharge from hospital to community settings: a systematic review.

July 22, 2020

View More

Related Resources

Retained Swabs Following Invasive Procedures: Themes Identified from a Review of NHS Serious Incident Reports.

April 16, 2024

Patient Safety Primers

Retained Surgical Items: Definition and Epidemiology.

January 4, 2024

Reducing retained foreign objects in the operating room: a quality improvement initiative.

December 20, 2023

Sentinel Event Alert 68: updated surgical fire prevention for the 21st Century.

November 8, 2023

Deficiencies in Facility Leaders' Response to Critical Surgical Events at the Michael E. DeBakey VA Medical Center in Houston, Texas.

October 25, 2023

Root causes and preventability of unintentionally retained foreign objects after surgery: a national expert survey from Switzerland.

July 19, 2023

Identifying a list of healthcare 'never events' to effect system change: a systematic review and narrative synthesis.

July 12, 2023

Patient safety trends in 2022: an analysis of 256,679 serious events and incidents from the nation’s largest event reporting database.

May 17, 2023

Factors contributing to preventing operating room "never events": a machine learning analysis.

May 10, 2023

The high cost of retained surgical items.

April 26, 2023

Development and interrater agreement of a novel classification system combining medical and surgical adverse event reporting.

April 19, 2023

Normalization of deviance is contrary to the principles of high reliability.

April 12, 2023

Surgical fire in the United States: 2000-2020.

March 15, 2023

Insurance claims for wrong-side, wrong-organ, wrong-procedure, or wrong-person surgical errors: a retrospective study for 10 years.

February 8, 2023

Am I safe? An interpretative phenomenological analysis of vulnerability as experienced by patients with complications following surgery.

January 18, 2023

Guidelines in Practice: prevention of unintentionally retained surgical items.

December 7, 2022

A multicenter collaborative effort to reduce preventable patient harm due to retained surgical items.

November 30, 2022

Eliminating Unintentionally Retained Surgical Items - Special Report.

September 21, 2022

Crisis recovery in surgery: error management and problem solving in safety-critical situations.

September 14, 2022

Preventing retained surgical items.

August 3, 2022

Patient falls in the operating room setting: an analysis of reported safety events.

May 11, 2022

Central venous catheter guidewire retention: lessons from England's never event database.

May 4, 2022

Effect of the surgical safety checklist on provider and patient outcomes: a systematic review.

April 27, 2022

Performance variability in perioperative sentinel events: report on a nationwide data set.

April 20, 2022

Increased adherence to perioperative safety guidelines associated with improved patient safety outcomes: a stepped-wedge, cluster-randomised multicentre trial.

February 9, 2022

Guideline for Prevention of Unintentionally Retained Surgical Items.

January 19, 2022

The nature of reported safety events related to care coordination in the operating room setting in a tertiary academic center.

November 17, 2021

Descriptive analysis of patient misidentification from incident report system data in a large academic hospital federation.

October 20, 2021

Evaluating the impact of radio frequency identification retained surgical instruments tracking on patient safety: literature review.

August 18, 2021

Prevalence and characteristics of interruptions and distractions during surgical counts.

July 28, 2021

View More

See More About The Topic

Outpatient Surgery

Quality and Safety Professionals

Retained Surgical Instruments and Sponges

To sign up for updates or to access your subscriber preferences, please enter your email address below.

5600 Fishers Lane
Rockville, MD 20857
Telephone: (301) 427-1364