Say Never!

say never

 

In my last blog I wrote about retained guidewires and why they are important to those of us in the Emergency Department. There were some tips on how to prevent retained guidewires through observership, redundancy, and good clear verbal and written documentation to promote absolute certainty that the guidewire has been removed. I also mentioned that this topic is one of patient safety, to the point that a retained guidewire in a patient is on the NHS England list of never events.

But, what are these ‘never events’? They exist, you’ve probably heard of the term at least, but do you know what they are? Do you know how they relate to your practice in the ED? These are questions that came up in the most recent FRCEM examination, but whilst they’re valuable knowledge for exams, they are also crucial to your day-to-day clinical work, and in trying to minimise harm to your patients.

Let’s find out a bit more.

 

What is a never event?

Never events have a very specific definition. They are a particular type of serious incident that meet all of the following criteria:

  • Potential to cause serious patient harm or death
  • Easily recognisable
  • Clearly defined
  • Wholly preventable
  • Evidence of previous occurrence
  • Risk of recurrence
  • National guidance for prevention in place

If a never event occurs, this denotes a failing in the system and should prompt a review of patient safety systems and procedures, ensuring implementation of any changes required to prevent recurrence. Reporting of such incidents is therefore necessary to improve patient safety, and to learn from our mistakes.

There is a list of never events which is published by NHS England and reviewed annually.

 

What’s on the list?

The list is divided into categories and then further into specific events.

Surgical

  • Wrong site surgery
  • Wrong implant/prosthesis
  • Retained foreign object

Medication

  • Mis-selection of a strong potassium-containing solution
  • Wrong route administration
  • Overdose of insulin due to abbreviations or incorrect device
  • Overdose of methotrexate for non-cancer treatment
  • Mis-selection of high strength midazolam during conscious sedation

Mental Health

  • Failure to install collapsible shower/curtain rails

General

  • Falls from poorly restricted windows
  • Chest/neck entrapment in bedrails
  • ABO-incompatible transfusion or transplantation
  • Misplaced naso/orogastric tubes
  • Scalding of patients during washing/bathing

 

Which never events are relevant to the ED?

From looking at the above list you can immediately see a few events which are very relevant to the ED. ABO-incompatible transfusion, midazolam selection, and all of the other medication events (with the exception of methotrexate administration) might happen in your emergency department on a daily basis. However, there are other things we do in the ED which you might not think of straight away that also appear in this list.

We perform surgical interventions – chest drains, nerve blocks, or regional blocks, and it is important to make sure we are doing these in the correct site, otherwise we are performing wrong site surgery – a never event. It’s always crucial to look at the chest x-ray before you put a chest drain in, to ensure you don’t try to drain the healthy hemithorax. Note that the definition of wrong site surgery excludes blocks for pain relief, such as a fascia iliaca block (but that’s not an excuse to get the side wrong!), but does include procedural blocks e.g. to reduce dislocations or suture wounds. If a chest drain was being inserted in theatre, the patient would be marked, and the WHO checklist completed before the procedure. Do you do this in your ED?

As discussed in the last blog, retained foreign objects – guidewires – comprise half of the never events reported in EDs across the country.

If you work in one of those lucky emergency departments that has windows, then don’t forget if your patient falls out of a window then that too is a never event. If you have windows, you probably will have noticed that they open less than an inch, just to be sure.

 

Entrapment in bedrails is certainly something that has the potential to occur in the ED. We have a huge volume of elderly or confused patients, with poor mobility, who are unwell, with the potential to try to climb out of bed via any gap they can find.

Sometimes, we even insert feeding nasogastric tubes – think of the patient who comes in having pulled their tube out. We insert a new one and send them home. Make sure correct placement is assessed and documented before they leave or start feeding/medicating through it, to avoid misplaced tubes.

There’s only really one or two items on the list that don’t apply in the ED (and even those may do in rare cases, which is when we really need to be careful – when was the last time you prescribed methotrexate in the ED? With bed problems across the country, it may be that the patient you’re admitting needs their methotrexate whilst they’re still in your care…)

 

What do we do about them?

Go to your department. Take a look at each never event. What processes has your department got in place to prevent these occurring.

How do you ensure the correct strength of midazolam is selected? Who checks it? Do you know the correct strength of midazolam in your vials?

Do you have a procedural checklist? Do you use it? How do you ensure correct drain placement, correct block site, guidewire removal?

What is your reporting process? Don’t forget, if you don’t know what a never event is, how are you going to ensure they get reported?

So, how can you improve patient safety in your ED? Over to you.

vb

Chris
@cgraydoc