Literature DB >> 28659678

'Never Events in Surgery': Mere Error or an Avoidable Disaster.

Jitendra Kumar1,2, Rajni Raina3.   

Abstract

Never events in surgery is not an uncommon occurrence. It is difficult to find any surgeon who never had an experience of one or another kind of mistake, committed while delivering the surgical care to the patient. Whatever the reports come out through news media or other sources are just a tip of iceberg. Collectively, its results, not only as a huge suffering and financial burden for the patients but also its impact on the operating surgeon and sometimes to related institute, are very far reaching and extremely negative. In spite of all of this, every one of us thinks this as an individual problem or one of the anecdotal media coverage. The aim of this study is to create an awareness among surgeon's fraternity and bring the attention of associations of surgeon bodies to this serious issue so that collective steps can be initiated to address it. In an attempt to find all the related information, an extensive search of literature in English language was performed using online search engines: PubMed NCBI database, Google search, and other digital sources available online. Error may be in the form of an act of commission, act of omission, error of planning, or error of execution, but whatever the reason, ultimate impacts are not less than disastrous, affecting individuals to global level. In addition to the enforcing authorities, all other stake holders should wake up and must take collective and comprehensive approach to create a safety system inside the health care organisations.

Entities:  

Keywords:  Medical error; Never events; Patient safety; Surgical negligence; Wrong surgery

Year:  2017        PMID: 28659678      PMCID: PMC5473801          DOI: 10.1007/s12262-017-1620-4

Source DB:  PubMed          Journal:  Indian J Surg        ISSN: 0973-9793            Impact factor:   0.656


  27 in total

Review 1.  Pushing the profession: how the news media turned patient safety into a priority.

Authors:  M L Millenson
Journal:  Qual Saf Health Care       Date:  2002-03

2.  Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III.

Authors:  A R Localio; A G Lawthers; T A Brennan; N M Laird; L E Hebert; L M Peterson; J P Newhouse; P C Weiler; H H Hiatt
Journal:  N Engl J Med       Date:  1991-07-25       Impact factor: 91.245

3.  Association between implementation of a medical team training program and surgical mortality.

Authors:  Julia Neily; Peter D Mills; Yinong Young-Xu; Brian T Carney; Priscilla West; David H Berger; Lisa M Mazzia; Douglas E Paull; James P Bagian
Journal:  JAMA       Date:  2010-10-20       Impact factor: 56.272

Review 4.  Achieving the National Quality Forum's "Never Events": prevention of wrong site, wrong procedure, and wrong patient operations.

Authors:  Robert K Michaels; Martin A Makary; Yasser Dahab; Frank J Frassica; Eugenie Heitmiller; Lisa C Rowen; Richard Crotreau; Henry Brem; Peter J Pronovost
Journal:  Ann Surg       Date:  2007-04       Impact factor: 12.969

5.  The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II.

Authors:  L L Leape; T A Brennan; N Laird; A G Lawthers; A R Localio; B A Barnes; L Hebert; J P Newhouse; P C Weiler; H Hiatt
Journal:  N Engl J Med       Date:  1991-02-07       Impact factor: 91.245

6.  Surgical never events and contributing human factors.

Authors:  Cornelius A Thiels; Tarun Mohan Lal; Joseph M Nienow; Kalyan S Pasupathy; Renaldo C Blocker; Johnathon M Aho; Timothy I Morgenthaler; Robert R Cima; Susan Hallbeck; Juliane Bingener
Journal:  Surgery       Date:  2015-05-29       Impact factor: 3.982

7.  Costs of medical injuries in Utah and Colorado.

Authors:  E J Thomas; D M Studdert; J P Newhouse; B I Zbar; K M Howard; E J Williams; T A Brennan
Journal:  Inquiry       Date:  1999       Impact factor: 1.730

8.  Patient safety: a call to action: a consensus statement from the National Quality Forum.

Authors:  K W Kizer
Journal:  MedGenMed       Date:  2001-03-21

9.  The incidence and nature of surgical adverse events in Colorado and Utah in 1992.

Authors:  A A Gawande; E J Thomas; M J Zinner; T A Brennan
Journal:  Surgery       Date:  1999-07       Impact factor: 3.982

10.  The importance of side marking in preventing surgical site errors.

Authors:  Dvora Pikkel; Adi Sharabi-Nov; Joseph Pikkel
Journal:  Int J Risk Saf Med       Date:  2014
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  3 in total

1.  Identification of Common Themes from Never Events Data Published by NHS England.

Authors:  Islam Omar; Yitka Graham; Rishi Singhal; Michael Wilson; Brijesh Madhok; Kamal K Mahawar
Journal:  World J Surg       Date:  2020-11-20       Impact factor: 3.352

2.  The quality of antimicrobial prescribing in acute care hospitals: results derived from a national point prevalence survey, Germany, 2016.

Authors:  Seven Johannes Sam Aghdassi; Frank Schwab; Sonja Hansen; Luis Alberto Peña Diaz; Michael Behnke; Petra Gastmeier; Tobias Siegfried Kramer
Journal:  Euro Surveill       Date:  2019-11

3.  Intraoperative practices to prevent wrong-level spine surgery: a survey among 105 spine surgeons in the United Kingdom.

Authors:  Ali Zain Naqvi; Henry Magill; Naffis Anjarwalla
Journal:  Patient Saf Surg       Date:  2022-01-26
  3 in total

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