Quality Improvement in the Perioperative Orthopedic Setting

Horvath, Michelle; Magid, Steven K.

doi:10.1007/978-1-4614-0100-1_30

Cited by 1 publication

(2 citation statements)

References 46 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…We excluded another 337 articles after reviewing the full-text citations largely because they neither identified individual NEs nor specified an existing framework (47%), or because they were non-scholarly (eg, media releases; 30%). Thus, our analyses were based on 367 articles 3 4 7–11 18–377. A full list of these articles and the information we extracted from them are found in online supplemental tables 1 and 2.…”

Section: Resultsmentioning

confidence: 99%

“…While legislating the reporting of NEs has benefits, it can also be restrictive and difficult to update 13. Furthermore, a culture of safety is needed to encourage compliance 41 62 141 155. In these organisations reporting systems are used for quality assurance, emphasising system change rather than disciplining individual providers 211 379–381…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Identifying a list of healthcare ‘never events’ to effect system change: a systematic review and narrative synthesis

et al. 2023

View full text Add to dashboard Cite

BackgroundNever events (NEs) are patient safety incidents that are preventable and so serious they should never happen. To reduce NEs, several frameworks have been introduced over the past two decades; however, NEs and their harms continue to occur. These frameworks have varying events, terminology and preventability, which hinders collaboration. This systematic review aims to identify the most serious and preventable events for targeted improvement efforts by answering the following questions: Which patient safety events are most frequently classified as never events? Which ones are most commonly described as entirely preventable?MethodsFor this narrative synthesis systematic review we searched Medline, Embase, PsycINFO, Cochrane Central and CINAHL for articles published from 1 January 2001 to 27 October 2021. We included papers of any study design or article type (excluding press releases/announcements) that listed NEs or an existing NE framework.ResultsOur analyses included 367 reports identifying 125 unique NEs. Those most frequently reported were surgery on the wrong body part, wrong surgical procedure, unintentionally retained foreign objects and surgery on the wrong patient. Researchers classified 19.4% of NEs as ‘wholly preventable’. Those most included in this category were surgery on the wrong body part or patient, wrong surgical procedure, improper administration of a potassium-containing solution and wrong-route administration of medication (excluding chemotherapy).ConclusionsTo improve collaboration and facilitate learning from errors, we need a single list that focuses on the most preventable and serious NEs. Our review shows that surgery on the wrong body part or patient, or the wrong surgical procedure best meet these criteria.

show abstract

Section: Resultsmentioning

confidence: 99%