Never Events in Healthcare
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Never Events in Healthcare

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Questions and Answers

Which of the following statements best describes a Never Event?

  • An event that has occurred in the past and cannot happen again.
  • An incident that leads to patient harm but is unavoidable.
  • A rare event that is difficult to define and recognize.
  • A patient safety incident that is largely preventable and can cause serious harm. (correct)

    • Serious harm or death must occur for an event to be classified as a Never Event.

    False

    What are the main categories into which Never Events are grouped?

    Surgical/invasive procedure, Medication, Mental Health, General

    A Never Event can lead to _ patient harm or even death.

    <p>serious</p> Signup and view all the answers

    Match the type of Never Event with its description.

    <p>Surgical/invasive procedure = Includes interventional procedures like surgery. Medication = Refers to errors related to medication administration. Mental Health = Concerns incidents occurring in mental health care settings. General = Covers broader patient safety incidents not specific to other categories.</p> Signup and view all the answers

    Which of the following is NOT included in the policy regarding Never Events?

    <p>Placement of peripheral IV lines</p> Signup and view all the answers

    The occurrence of Never Events can be minimized by following established guidelines and recommendations.

    <p>True</p> Signup and view all the answers

    What is one reason for focusing on Never Events in healthcare?

    <p>To improve patient safety and minimize serious incidents.</p> Signup and view all the answers

    At what point does surgery officially begin?

    <p>At the point of surgical incision</p> Signup and view all the answers

    The surgeon is solely responsible for the surgical outcome of a patient.

    <p>False</p> Signup and view all the answers

    What are 'Never Events'?

    <p>Serious, preventable errors in medical care that should never occur.</p> Signup and view all the answers

    An invasive procedure performed on the wrong patient is classified as a __________.

    <p>Never Event</p> Signup and view all the answers

    Match the following errors with their descriptions:

    <p>Wrong patient invasive procedure = Procedure performed on the incorrect patient Wrong site surgery = Procedure performed at the incorrect site Wrong surgery performed = Invasive procedure not consistent with consent Wrong implant placed = Implant different from that in procedural plan</p> Signup and view all the answers

    Which of the following is NOT considered a Never Event?

    <p>Blood taken from wrong patient</p> Signup and view all the answers

    Wrong site surgery includes procedures like wrong site dental procedures.

    <p>False</p> Signup and view all the answers

    What is a common cause of wrong patient surgeries?

    <p>More than one patient on the list with similar names.</p> Signup and view all the answers

    The surgeon, scrub practitioner, and surgical representative must confirm the __________ of the implant before placement.

    <p>correctness</p> Signup and view all the answers

    What constitutes a 'wrong site or side' error?

    <p>Performing surgery on a different body part than intended</p> Signup and view all the answers

    Removing the wrong tooth counts as a Never Event.

    <p>False</p> Signup and view all the answers

    What must be documented when a procedure is changed due to unexpected anatomical abnormalities?

    <p>The change must be documented in the patient's notes.</p> Signup and view all the answers

    A __________ can occur if a biopsy is performed on a patient that is not consistent with the informed consent.

    <p>wrong surgery</p> Signup and view all the answers

    Match the surgical scenarios with their classifications:

    <p>Intervention on wrong site = Wrong site surgery Surgery on wrong patient = Wrong patient invasive procedure Performing wrong procedure = Wrong surgery performed Implantation of incorrect device = Wrong implant or prosthesis</p> Signup and view all the answers

    What is an unintended retained foreign body after surgery?

    <p>An item improperly counted or not removed after a procedure</p> Signup and view all the answers

    A strong potassium solution can be given intravenously without concerns if intended for the patient.

    <p>False</p> Signup and view all the answers

    What is a common consequence of a failure to install functional collapsible shower or curtain rails?

    <p>Suicide attempts or completions</p> Signup and view all the answers

    The retention of a foreign body is defined as its presence after the completion of _______ closure.

    <p>skin</p> Signup and view all the answers

    Match the event with its description:

    <p>Misplaced naso- or oro-gastric tubes = Tube placed in the wrong anatomical area ABO-incompatible transfusion = Unintentional transfusion of mismatched blood Falls from poorly restricted windows = Patient falls from windows that are accessible Scalding of patients = Patient burns from hot water used in bathing</p> Signup and view all the answers

    What is NOT excluded from the definition of unintended retention of foreign bodies?

    <p>Action taken to retrieve known missing items</p> Signup and view all the answers

    Administration of oral medication via parenteral routes is acceptable in healthcare.

    <p>False</p> Signup and view all the answers

    What is required for a transfusion of ABO-incompatible blood?

    <p>Appropriate management</p> Signup and view all the answers

    Chest or neck entrapment in bed rails is considered a _____ event.

    <p>Never</p> Signup and view all the answers

    Match the medication errors with their descriptions:

    <p>Strong potassium solution = IV administration of potassium chloride Route misadministration = Incorrect delivery route for medication Scalding = Burns from washing or bathing water Transfusion error = Mismatched blood transfusion</p> Signup and view all the answers

    What oversight can lead to the misplacement of naso- or oro-gastric tubes?

    <p>Failure to monitor during feeding</p> Signup and view all the answers

    Incorrect prosthesis use is acceptable if it considers clinical judgment.

    <p>False</p> Signup and view all the answers

    Name one type of object considered a foreign body during a surgical procedure.

    <p>Swabs, needles, instruments</p> Signup and view all the answers

    An unintended transfusion occurs when ABO-incompatible blood is introduced to the patient without ________.

    <p>appropriate management</p> Signup and view all the answers

    Which of the following is a risk related to poorly restricted windows?

    <p>Access within reach of patients</p> Signup and view all the answers

    Study Notes

    Never Events

    • Never Events are preventable patient safety incidents that can cause serious harm or death.
    • These incidents are defined as clearly identifiable events related to clinical treatment that have led to patient harm and are easily recognized.
    • Never Events are categorized into: Surgical/invasive procedure, Medication, Mental Health, and General.
    • Each incident must be thoroughly investigated to identify the cause and implement improvements to prevent future occurrences.

    Surgical/Invasive Procedure Never Events

    • Wrong patient invasive procedure or surgery: Procedures performed on the wrong patient due to identification errors.
      • Includes: Nerve blocks, biopsies, interventional radiology and cardiology procedures, drain insertion, and line insertion.
      • Excludes: Blood draws, peripheral IV line insertion, urinary catheter insertion, and blood transfusions (although these are considered serious events requiring reporting).
    • Wrong site or side invasive procedure or surgery: Procedures performed at the wrong site or side despite documented consent and planning.
      • Includes: Procedures performed at the incorrect site, such as the wrong knee or eye.
      • Excludes: Removal of the wrong teeth, interventions with unknown anatomical abnormalities, wrong site surgery due to incorrect laboratory reports or referrals, and contraceptive implant in the wrong arm.
    • Wrong surgery or invasive procedure performed: Procedures performed that are not consistent with the documented informed consent and planning.
      • Includes: Incomplete surgical procedures where one of the procedures is not performed due to failure to perform safety checks.
      • Excludes: Procedures intentionally changed due to unknown anatomical abnormalities, procedures intentionally not completed due to operative risk, complexity, or patient factors.
    • Wrong implant or prosthesis: Implantation of a device that is different from that specified in the procedural plan.
      • Includes: Implantation of the wrong intrauterine contraceptive device or prosthesis.
      • Excludes: Implants intentionally different from the plan based on clinical judgment, devices placed as planned but later found to be suboptimal, implants different due to incorrect preprocedural measurements or interpretation.
    • Unintended retained foreign body after surgery or invasive procedure: Foreign objects left behind after a surgical procedure.
      • Includes: Items subject to formal counting and checking processes, such as swabs, needles, instruments, and retractor pads.
      • Excludes: Items not subject to formal counting but accidentally left behind (e.g., peripheral IV line).

    Medication Never Events

    • Mis-selection of a strong potassium solution: Administration of a strong potassium solution intravenously instead of the intended medication.
    • Administration of medication by the wrong route: Administration of medication through the incorrect route, for example, intravenous chemotherapy administered intrathecally.

    Mental Health Never Events

    • Failure to install functional collapsible shower or curtain rails: Failure of collapsible rails to prevent suicide attempts or completed suicides.

    General Never Events

    • Falls from poorly restricted windows: Falls from windows accessible to patients, particularly in healthcare facilities.
    • Chest or neck entrapment in bed rails: Patient entrapment between bed rails or in the bedframe or mattress due to non-compliant bed rail dimensions.
    • Transfusion or transplantation of ABO-incompatible blood components or organs: Unintentional transfusion or transplantation of ABO-incompatible blood components or organs.
    • Misplaced naso- or oro-gastric tubes: Misplacement of naso- or oro-gastric tubes in the pleura or respiratory tract before starting medication administration.
    • Scalding of patients: Patients scalded by water used for washing or bathing.
    • Unintentional connection of a patient requiring oxygen to an air flowmeter: Connection of a patient requiring oxygen to an air flowmeter instead of an oxygen flowmeter.

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    Description

    Explore the critical topic of Never Events in healthcare, focusing on preventable patient safety incidents. This quiz covers various categories, including surgical procedures, medication errors, and mental health incidents. Learn how these events can lead to serious harm or death and the importance of thorough investigations to prevent future occurrences.

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