Place of death is undoubtedly an important factor in achieving a good death for some patients and carers. However, for others a home death is either unimportant or to be avoided. The results of this study, and the results of similar studies, suggest that place of death may not be a good marker of the quality of end of life care.

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ObjectivesGuidewire retention during central venous catheter (CVC) insertion is considered a “never event.” We analyzed the National Health Service England Never Event database (2004–2015) to explore the process of guidewire retention and identify potential preventative measures.MethodsWe performed a systematic analysis of reported retained guidewire incidents by 3 independent reviewers.ResultsThere was a rising frequency of reported retained CVC guidewires, with an average of 2 never events per month. Only 11% of retained guidewires are identified during the procedure itself, with the remainder identified during equipment clear-up (6%), after the procedure (4%), at the first check radiograph (23%), or after the first radiograph (55%). In 59 cases, the grade of the operator was reported, and among these, 88% were inserted by trainee doctors. Analysis of causative factors was only possible for 38 cases, and of these, operator’s mistake (32%), operator/human error (16%), and distraction (16%) were the most common. Of 163 reported cases, preventative measures instigated were actions taken against the individual clinician (36%), departmental actions such as investigations, additional teaching or reminders (37%), and additional checklists (27%).ConclusionsMost retained guidewires are discovered after the procedure. Despite the introduction of safety measures, guidewire retention still occurs because the checks, alerts, reminders, and additional checklists all solely rely on the operator remembering not to make the mistake. System changes or design modifications to the CVC equipment are needed to prevent guidewire retention, this being at the top of the hierarchy of intervention effectiveness.

The new double hitch was superior to all conventional knots tested. It did not slip under any conditions and therefore may be of use to prevent unintentional extubation, particularly in the ICU setting.

Poor, biased reporting of daily covid death statistics without perspective creates fear Holly Young consultant palliative medicine Abbasi calls for redress for the mishandling of the pandemic. 1 But mainstream media outlets report daily death statistics in a way that does not support understanding or provide perspective of what is an inevitable and natural process, reinforcing the United Kingdom's terror of death by creating fear with poor and biased reporting.