Never Events in Orthopaedics: A Nationwide Data Analysis and Guidance on Preventative Measures

Description

In this presentation, Ahmed Hafez discusses the critical issue of Never Events in orthopedic surgery, highlighting their preventable nature and significant impact on patient safety. He introduces the concept of Never Events as serious, wholly preventable clinical incidents that can occur if appropriate safeguards are not followed. Hafez outlines the findings of a nationwide observational study led by Professor Kamal Mahawar, revealing that among the approximately 3,000 reported Never Events, around 460 were related to orthopedics, making up about 14% of the total. The analysis identified key themes such as wrong implants and surgical procedures, which accounted for 48% and 15% of these events, respectively. Hafez provides detailed statistics on the types of orthopedic incidents, with the most common being wrong procedures and wrong site surgeries. He emphasizes the importance of implementing recommended safety protocols, including effective team briefings, written communication of plans, and thorough counting of surgical instruments to mitigate risks. Hafez also references previous studies that propose technologies such as barcode scanning to enhance safety during surgeries. The presentation concludes with a call for increased awareness and adherence to safety standards while engaging the audience in a Q&A session to discuss the implications and recommendations for minimizing Never Events in orthopedic practices.

DOI: 10.1302/3114-221387

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