Bariatric Unit, Department of General Surgery, Sunderland Royal Hospital, South Tyneside and Sunderland NHS Trust, Kayll Rd, Sunderland SR4 7TP, UK.
Bariatric & Upper GI Surgery Unit, Birmingham Heartlands Hospital, University Hospital Birmingham NHS Foundation Trust, Bordesley Green E, Birmingham B9 5SS, UK.
Int J Qual Health Care. 2021 Mar 17;33(1). doi: 10.1093/intqhc/mzab045.
There is little available data on common general surgical never events (NEs). 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 NEs from the data held by the National Health Service (NHS) England.
We analysed the NHS England NE data from April 2012 to February 2020 to identify common general surgical NEs.
There was a total of 797 general surgical NEs identified under three main categories such as wrong-site surgery (n = 427; 53.58%), retained items post-procedure (n = 355; 44.54%) and wrong implant/prosthesis (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 categories and six in wrong implants category.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/angiograms. There were seven (1.6%) instances of confusion in pilonidal/perianal/perineal surgeries and six (1.4%) instances of biopsy of the cervix rather than the 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 guide wires, 26 (7.3%) surgical needles and 9 (2.5%) surgical drains. Wrong stents were the most common (n = 9; 60%) wrong implants followed by wrong breast implants (n = 2; 13.3%).
This study found 56 common general surgical NEs. This information is not available to surgeons around the world. Increased awareness of these common themes of NEs may allow for the adoption of more effective and specific safeguards and ultimately help reduce their incidence.
关于普通普外科的严重医疗差错（NE），目前仅有少量数据。由于缺乏这些信息，我们可能难以降低这些潜在严重临床事件的发生率。
本研究旨在从英国国家医疗服务体系（NHS）的数据中确定常见的普外科 NE。
我们分析了 NHS 英格兰从 2012 年 4 月至 2020 年 2 月的 NE 数据，以确定常见的普外科 NE。
共有 797 例普外科 NE 分为三大类：手术部位错误（n=427；53.58%）、术后遗留异物（n=355；44.54%）和植入物/假体错误（n=15；1.88%）。我们确定了 56 个普外科常见主题——手术部位错误和遗留异物各 25 个，植入物错误 6 个。手术部位皮肤状况错误是最常见的手术部位错误（n=117；27.4%）。有 18 例错误的胸腔引流管（4.2%）和 18 例（4.2%）错误的血管成形术/血管造影。有 7 例（1.6%）肛周/会阴/直肠手术中存在混淆，6 例（1.4%）宫颈活检而非结肠或直肠活检。遗留的手术拭子是最常见的遗留异物（n=165；46.5%）。有 28 例（7.9%）带或不带标本的腹腔镜回收袋、26 例（7.3%）胸腔引流导丝、26 例（7.3%）手术针和 9 例（2.5%）引流管。错误的支架是最常见的错误植入物（n=9；60%），其次是错误的乳房植入物（n=2；13.3%）。
本研究发现了 56 个普外科常见的 NE。世界各地的外科医生都不知道这些信息。提高对这些 NE 常见主题的认识，可能有助于采用更有效和具体的防范措施，并最终有助于降低其发生率。
