Never events in orthopaedics: A nationwide data analysis and guidance on preventative measures.

Pub Date : 2022-01-01 DOI:10.3233/JRS-210051

Ahmed T Hafez, Islam Omar, Balaji Purushothaman, Yusuf Michla, Kamal Mahawar

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引用次数: 1

Abstract

Background: Never Events (NE) are serious clinical incidents that are wholly preventable if appropriate institutional safeguards are in place and followed. They are often used as a surrogate of the quality of healthcare delivered by an institution. Most NEs are surgical and orthopaedic surgery is one of the most involved specialties.

Objective: The aim of this study was to identify common NE themes associated with orthopaedics within the National Health Service (NHS) of England.

Method: We conducted an observational study analysing the annual NE data published by the NHS England from 2012 to 2020 to collate all orthopaedic surgery-related NE and construct relevant recurring themes.

Results: We identified 460 orthopaedic NE out of a total of 3247 (14.16%) reported NE to NHS England. There were 206 Wrong implants/prostheses under 8 different themes. Wrong hip and knee prosthesis were the commonest "wrong implants" (n = 94; 45.63% and n = 91; 44.17% respectively). There were 197 "wrong-site surgery" incidents in 22 different themes. The commonest of these was the laterality problems accounting for 64 (32.48%) incidents followed by 63 (31.97%) incidents of wrong spinal level interventions. There were 18 (9.13%) incidents of intervention on the wrong patients and 17 (8.62%) wrong incisions. Retained pieces of instruments were the commonest retained foreign body with 15 (26.13%) incidents. The next categories were retained drill parts and retained instruments with 13 (22.80%) incidents each.

Conclusion: We identified 47 different themes of NE specific to orthopaedic surgery. Awareness of these themes would help in their prevention. Site marking can be challenging in the presence of cast and on operating on the digits and spine. Addition of a real-time intra-operative implant scan to the National Joint Registry can avoid wrong implant selection while fiducial markers, intraoperative imaging, O-arm navigation, and second time-out could help prevent wrong level spinal surgery.

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骨科中未发生的事件:一项全国性的数据分析和预防措施指导。

背景:Never Events (NE)是严重的临床事件，如果适当的制度保障措施到位并得到遵守，这些事件是完全可以预防的。它们通常被用作机构提供的医疗保健质量的替代品。大多数神经内科是外科的，而矫形外科是涉及最多的专业之一。目的:本研究的目的是确定英国国家卫生服务(NHS)中与骨科相关的常见NE主题。方法:我们进行了一项观察性研究，分析了2012年至2020年英国NHS公布的年度NE数据，整理了所有与骨科手术相关的NE，并构建了相关的重复主题。结果:我们从3247例(14.16%)向英国NHS报告的NE中确定了460例骨科NE。8个不同主题共206个假体/假体错误。错误的髋关节和膝关节假体是最常见的“错误植入物”(n = 94;45.63%， n = 91;44.17%)。在22个不同的主题中有197例“手术部位错误”事件。其中最常见的是侧位问题，占64例(32.48%)，其次是63例(31.97%)错误的脊柱水平干预。错误患者干预18例(9.13%)，错误切口17例(8.62%)。器械残留是最常见的异物，有15例(26.13%)。其次是钻头零件和仪器，各有13起(22.80%)事故。结论:我们确定了47个不同的骨科手术NE主题。了解这些主题将有助于预防这些问题。现场标记可能是具有挑战性的存在铸造和操作上的数字和脊柱。在国家联合登记处增加实时术中植入物扫描可以避免错误的植入物选择，而基准标记，术中成像，o型臂导航和第二次暂停可以帮助防止错误的脊柱手术。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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