The A-Z of Patient Care - N is for Never event

Safety is a priority when it comes to surgery, and that is why surgical teams make sure to take every precaution to reduce mistakes which can prove fatal to patient wellbeing.

N is for Never event

Did you know that NHS England spends over 16 billion pounds on elective surgery and performs over 10 million operations each year?1 With this in mind, it is important to know that patient safety is always the first priority for any surgical team. Unfortunately, serious mistakes can occasionally occur and are known as ‘Never events’. The term “Never event” was first introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF), in reference to particularly shocking medical errors that should never occur.2

 

When surgery goes wrong...

 

In truth, ‘Never events’ are quite gruesome. One report follows a post-op patient finding a six-inch pair of rusted surgical scissors next to his colon3, the scissors had been in the patient’s body for 18 years before surgeons removed them. The man originally had a procedure after a severe car accident. After the surgery, he experienced abdominal pains which prescribed medications did not cure. Doctors finally decided to X-ray him and discovered surgical equipment left by their colleagues almost two decades before! 4

 

 

Another example of a horrifying Never event was when surgeons performed unnecessary brain surgery on the wrong patient! Originally the man was due to undergo a non-invasive procedure to reduce the swelling in his head. However due to a patient mix up, the surgeons ended up performing an operation to remove a blood clot on his brain. The surgical team only realised their mistake hours into the surgery. Miraculously the patient made a full recovery and suffered from no further damage.5

 

 

Both incidents are equally alarming. However, this next case is particularly shocking. Sixteen surgical instruments were discovered inside a 74-year-old male patient’s abdomen following a routine surgery for prostate cancer. Items included: a needle, a six-inch roll of bandage, a six-inch long compress, several swabs and fragments of a surgical mask. Within a few months of surgery, the patient suffered severe abdominal pain, which he described as ‘appalling agony’ and was rushed back into theatre to have the foreign objects removed.6

 

Preventing Never events

‘The Count’ is a procedure which takes place before a patient enters the operating theatre and after the closure of the wound. Scrub nurses and surgeons count out-loud and precisely document each surgical instrument and material to be used in the operation.7   Scarily, there were a reported 43 cases of Never events that related to surgical swabs being found inside patients between 2017 and 2018.8

The Detex™ range consists of X-ray detectable swabs grouped into ‘tied 5s’. A red tie is placed around 5 swabs to aid the surgical counting procedure. The red ties are removed from the gauze swabs pre-surgery and retained to help with the post-surgery count. For example, five retained red ties means twenty-five swabs should be counted post-surgery. The X-ray detectable line on Vernacare Detex™ swabs ensures the surgical team can identify them under an X-ray if there are any that mistakenly get left inside the body, allowing them to be removed quickly and safely.

X-ray detectable lines are used throughout the Vernacare surgical products and can be found in the BERT® laparoscopic retrieval bag range. BERT® retrieval bags were introduced to hospitals in 19929, providing a safe solution for the removal of tissue for a wide range of laparoscopic procedures. 

Feel better yet?

In 2018, 452 Never events occurred in UK hospitals, which is a small number in comparison to the 11 million successful surgeries reported in the UK every year!10

Here at Vernacare, we work closely with hospital staff and surgical teams around the world to provide enhanced surgical solutions that put patient safety first.

 

If you want to find out more about our surgical solutions range click here!
arrow-diagonal-up-right Created with Sketch.

 

 

References

  1. (2019). The Perioperative Journey. [online] Available at: https://www.youtube.com/watch?v=KxIHwPUuziQ [Accessed 28 Jan. 2019].
  2. ahrq.gov. (2019). Never Events | AHRQ Patient Safety Network. [online] Available at: https://psnet.ahrq.gov/primers/primer/3 [Accessed 22 Jan. 2019].
  3. HuffPost UK. (2019). Doctors Remove Scissors From Man's Abdomen After 18 Years. [online] Available at: https://www.huffingtonpost.co.uk/entry/surgical-scissors-stuck-18-years_us_586c2b45e4b0eb58648b052e [Accessed 24 Jan. 2019].
  4. Mail Online. (2019). Surgeons remove rusty SCISSORS from man’s abdomen after 18 years. [online] Available at: https://www.dailymail.co.uk/news/article-4083652/Surgeons-remove-rusty-pair-6-inch-SCISSORS-man-s-abdomen-18-years-mistakenly-left-surgery.html [Accessed 28 Jan. 2019].
  5. BBC News. (2019). Wrong patient given brain surgery. [online] Available at: https://www.bbc.co.uk/news/world-africa-43255648 [Accessed 22 Jan. 2019].
  6. Mail Online. (2019). Blundering surgeons left SIXTEEN different objects in German pensioner's body after operation for prostate cancer. [online] Available at: https://www.dailymail.co.uk/news/article-2262797/Surgeon-left-16-items-body-Dirk-Schroeder-German-pensioner-dies-botched-operation.html [Accessed 22 Jan. 2019].
  7. org.au. (2019). Surgery : Surgical Count. [online] Available at: https://www.rch.org.au/surgery/local_procedures/Surgical_Count/ [Accessed 24 Jan. 2019].
  8. nhs.uk. (2019). Never Events data | NHS Improvement. [online] Available at: https://improvement.nhs.uk/resources/never-events-data/ [Accessed 24 Jan. 2019].
  9. com. (2019). [online] Available at: https://www.vernacare.com/media/2345/su332_bert_brochure_single_page_rev00.pdf [Accessed 28 Jan. 2019].
  10. nhs.uk. (2019). Never Events data | NHS Improvement. [online] Available at: https://improvement.nhs.uk/resources/never-events-data/ [Accessed 24 Jan. 2019].