Common General Surgical Never Events: Analysis of NHS England Never Events Data.

Omar, Islam, Singhal, Rishi, Wilson, Michael, Parmar, Chetan, Khan, Omar and Mahawar, Kamal (2021) Common General Surgical Never Events: Analysis of NHS England Never Events Data. International journal for quality in health care : journal of the International Society for Quality in Health Care. ISSN 1464-3677.

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There is little available data on common general surgical Never Events (NE). Lack of this information may have affected our attempts to reduce the incidence of these potentially serious clinical incidents. The purpose of this study was to identify common general surgical NE from the data held by the National Health Service (NHS) England.


We analysed NHS England NE data from April 2012 to February 2020 to identify common general surgical NE.


There was a total of 797 general surgical NE identified under three main categories of Wrong-Site Surgery (n=427;53.58%), Retained Items Post-Procedure (n=355; 44.54%), and Wrong Implant/Prosthesis and (n=15; 1.88%). We identified a total of 56 common general surgical themes - 25 each in the Wrong-Site Surgery and Retained Foreign Body category and 6 in wrong implants.Wrong skin condition surgery was the commonest wrong-site surgery (n=117; 27.4%). There were 18 wrong side chest drains (4.2%) and 18 (4.2%) wrong side angioplasty/angiogram. There were 7 (1.6%) instances of confusion in pilonidal/perianal/perineal surgeries and 6 (1.4%) instances of biopsy of cervix rather than colon or rectum.Retained surgical swabs were the most common retained items (n=165;46.5%). There were 28 (7.9%) laparoscopic retrieval bags with or without the specimen, 26 (7.3%) chest drain guidewires, 26 (7.3%) surgical needles; and 9 (2.5%) surgical drains. Wrong stents were most common (n=9;60%) wrong implant followed by wrong breast implants (n=2;13.3%).


This study found 56 common general surgical Never Events. This information is not available to surgeons around the world. Increased awareness of these common themes of NE may allow for adoption of more effective, specific safeguards and ultimately help reduce their incidence.

Item Type: Article
Subjects: WA Patients. Primary care. Medical profession. Forensic medicine
WO Surgery
Divisions: Planned IP Care > General Surgery
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Depositing User: Mrs Yolande Brookes
Date Deposited: 15 Mar 2021 17:55
Last Modified: 15 Mar 2021 17:55

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