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. 2024 Feb 1;5(5):433-437.
doi: 10.1002/bco2.331. eCollection 2024 May.

Urology never events in the United Kingdom: A retrospective 10-year review

Jerocin Vishani Loyala  1 , Andrew Ang  1 , Billy Down  1 , Sarah A Howles  1   2
Affiliations

Urology never events in the United Kingdom: A retrospective 10-year review

Jerocin Vishani Loyala et al. BJUI Compass. .

Erratum in

  • Erratum.
    [No authors listed] [No authors listed] BJUI Compass. 2024 Dec 30;5(12):1324-1329. doi: 10.1002/bco2.482. eCollection 2024 Dec. BJUI Compass. 2024. PMID: 39744071 Free PMC article.

Abstract

Objectives: The aim was to assess the prevalence of never events (NEs) specific to urology in the United Kingdom and identify commonly occurring themes.

Methods: Data from the National Health Service (NHS) NEs website were obtained and all NEs from 2012 to 2022 were reviewed. Urology-specific NEs were identified and further analysed in their respective categories. Data regarding the total number of surgical procedures performed in the NHS specific to each specialty were obtained via the NHS Hospital Episode Statistics website.

Results: There were 3972 NEs recorded over the 10-year period with 95 (2.4%) of these as a result of urology surgery. The most common surgical intervention associated with a urological NE was ureteric stenting, which comprised 45/95 (47.4%) of all analysed NEs. These consisted of wrong site ureteric stent insertion (n = 29), wrong site ureteric stent removal (n = 9), wrong stent type (n = 5) and retained guidewires (n = 2). There were 7.14 million urology surgeries performed in the 10-year period, and prevalence was 0.0013%.

Conclusion: NEs are fully preventable serious incidents in the NHS. This is the first study to investigate the prevalence of NEs in urology in the United Kingdom. This study demonstrates that in the last 10 years the prevalence of urology NEs is low at 0.0013%, with ureteric stent procedures accounting for more than half of the NEs. Urologists should be mindful of the potential for wrong site surgery in urologic stenting procedures.

Keywords: clinical governance; human factors; never events; patient safety.

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Conflict of interest statement

Sarah A. Howles is a Wellcome Trust Clinical Career Development Fellow. This research was funded in part by the Wellcome Trust 220 668/Z/20/Z. For the purpose of Open Access, the author has applied a CC BY public copyright licence to any Author Accepted Manuscript (AAM) version arising from this submission. Jerocin Vishani Loyala, Andrew Ang and Billy Down have no conflicts of interest to declare.

Figures

FIGURE 1
FIGURE 1
Urology‐specific never events by year reported.
See this image and copyright information in PMC

References

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