Anaesthesia and Critical Care Section, Division of Clinical Neuroscience, Queen's Medical Centre, University of Nottingham, Nottingham, UK.
Department of Anaesthesia, Nottingham University Hospitals, Nottingham, UK.
Anaesthesia. 2016 Jan;71(1):17-30. doi: 10.1111/anae.13290. Epub 2015 Nov 23.
Never Events are medical errors that are believed to be preventable with appropriate measures. We surveyed all English acute NHS trusts to determine the number of surgical Never Events and surgical caseload for 2011-2014. There were 742 surgically related Never Events in three years, with no change in the number annually. The risk of a surgical Never Event was 1 in 16 423 operations (95% CI 1 in 15 283 to 1 in 17 648) or 1 Never Event per 12.9 operating theatres per year (95% CI 1 in 12.1 to 1 in 13.9). The risk of severe harm due to a Never Event was approximately 1 in 238 939 operations. There was no meaningful association between number of Never Events and other safety indicators. Surgical Never Events are undoubtedly important to individual patients, but they are not a useful metric to judge quality of care.
“Never Events”是指那些被认为可以通过适当措施预防的医疗差错。我们调查了所有英国急性国民保健服务信托基金，以确定 2011 年至 2014 年期间发生的外科“Never Events”数量和手术工作量。三年内共发生 742 起与手术相关的“Never Events”，每年的数量没有变化。外科“Never Event”的风险为每 16423 例手术 1 例（95%CI 每 15283 例至每 17648 例 1 例）或每年每 12.9 个手术室 1 例（95%CI 每 12.1 例至每 13.9 例 1 例）。由于“Never Event”而导致严重伤害的风险约为每 238939 例手术 1 例。“Never Event”的数量与其他安全指标之间没有明显的关联。外科“Never Events”对个别患者无疑很重要，但它们不是衡量护理质量的有用指标。
