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Never events on ICU

  1. Serious incidents that are wholly preventable
  2. Potential to cause serious patient harm or death (whether or not harm actually happened)
  3. Protective national recommendations should have been implemented by all healthcare providers

 

(From the NHS 2015 updated never-events list.)

Many of these may seem ridiculously obvious but the point is that they happen, and should never. This is a selection of those that are most relevant to ICU:

Never be a part of these:

Death or harm relating to:

1. Wrong site surgery

Does include worng site block (unless for pain only).

Does include wrong site drain and line insertion.

2. Wrong implant or prosthesis

This doesn’t include lines or drains.

3. Retained foreign object post-procedure

This DOES include guidewires. And now specified that it is not only in circumstances where there’s a formal item count; ie. doing a central line on a ward/ICU.

Except where the item is known to be missing before the end of the procedure, ie in the case of a lost guidewire, if you notice it before you finish the procedure it’s not technically (yet) a NE.

4. Wrongly prepared high-risk injectable medication

Includes many of the drugs we draw up and use (eg sedatives and inotropes etc).

5. Maladministration of a potassium-containing solution.

Wong drug, wrong site or wrong rate

6. Wrong route administration of oral/enteral treatment.

ie. oral preparation given iv – it happens.

7. Intravenous administration of epidural medication

8. Maladministration of insulin

Do not abbreviate units to ‘u’

Avoid verbal orders

9. Overdose of midazolam during conscious sedation

Inadvertent use of high strength midazolam.

ICU actually excluded, but we work all over the hospital.

10. Opioid overdose of opioid-naïve patient

Death or severe harm if exceeds local policy, or prescriber fails to ensure they are familiar with the drug,

11. Transfusion of ABO incompatible blood components

12. Misplaced naso- or orogastric tubes

Misplacement AND use. Any flush,feed or medicine counts as use.

Removed between 2012 and 2015 (explanations in document):
  • Failure to monitor and respond to oxygen saturation
  • Air embolism
  • Wrong gas administered
  • Misidenification of patients
  • Maternal death due to postpartum haemorrhage

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