Across England, 344 never-events happened, with wrong-site surgery
making up 138 of them.
Examples of sentinel event alerts include alerts about preventing wrong-site surgery
, safe use of opioids, preventing medication errors, preventing violence, and preventing infections.
The term "Never Event" was first used in 2001 in reference to alarming events, such as wrong-site surgery
. Since then, the list (3) of "Never Events" has increased to identify adverse events that fall into three categories:
In a retrospective survey, medical errors in ENT were reported as follows: technical 19.3%, medical management 13.7%, testing 10.4%, surgical planning 9.9%, equipment-related 9.4%, postoperative care 8.5%, administrative 6.6%, wrong-site surgery
6.1%, communication 3.8%, wrong drug/dilution on the surgical field 3.8%, anesthesia-related 3.3%, history/physical and differential/final diagnosis (both 1.4%), retained foreign body and miscellaneous (both 0.9%), and nursing/ancillary 0.5%.
Operating room briefings and wrong-site surgery
. J Am Coll Surg.
(16) The Joint Commission has identified factors that may enhance the risk of wrong-site surgery
: multiple surgeons involved in the case, multiple procedures during a single surgical visit, unusual time pressures to start or complete the surgery, and unusual physical characteristics including morbid obesity or physical deformity.
Prevention of MEs such as wrong-site surgery
, medication errors, and patient falls are important issues for PS practices in the OR.
is a frequent problem for dermatologists.
(3) Specific clinical interventions are needed to reduce wrong-site surgery
(WSS), including wrong- site tooth extraction which is a rare but potentially disastrous clinical error.
* Identifying a reduced exposure to issues such as infection or wrong-site surgery
The report also includes details of a wrong-site surgery
case in July 2011 where a surgeon started operating on the wrong tooth during dental extraction.
He covers principles of medical malpractice; errors, incidents, and complications in general surgery; retained surgical foreign bodies; quality management related to wrong-site surgery
; towards a preventative safety culture within the hospital; and ethical aspects of an open safety culture: towards a new physician-patient relationship in 21st-century medicine.