Surgical Never Events. Learning from 38 cases occurring in English hospitals between April 2016 and March 2017

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Title: Surgical Never Events. Learning from 38 cases occurring in English hospitals between April 2016 and March 2017
Authors: Burnett, S
Item Type: Report
Abstract: NHS providers are encouraged to learn from mistakes and any organisation that reports a Never Event is expected to conduct its own investigation so it can learn from and take action on the underlying causes. This report presents an analysis of the local investigation reports into 38 surgical Never Events from across England that occurred between April 2016 and March 2017 (the last full year with data available). Although commissioned as part of our evaluation of the implementation of the national surgical safety standards for invasive procedures (NatSSIPs) — the learnings presented in the report will support providers to improve patient safety.
Issue Date: 12-Sep-2018
URI: http://hdl.handle.net/10044/1/72410
Publisher: NHS Improvement
Journal / Book Title: Surgical Never Events. Learning from 38 cases occurring in English hospitals between April 2016 and March 2017
Copyright Statement: © NHS Improvement 2018. Open Government Licence v3.
Keywords: Never Events
Surgery
Article Number: Publication code: R&A 04/18
Appears in Collections:Division of Surgery
Faculty of Medicine



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