Defining healthcare never events to effect system change: A protocol for systematic review.

Autor: Zaslow J; The Canadian Medical Protective Association, Ottawa, ON, Canada., Fortier J; The Canadian Medical Protective Association, Ottawa, ON, Canada., Bowman C; The Canadian Medical Protective Association, Ottawa, ON, Canada., de Gorter R; The Canadian Medical Protective Association, Ottawa, ON, Canada., Tsai E; The Canadian Medical Protective Association, Ottawa, ON, Canada., Desai D; The Canadian Medical Protective Association, Ottawa, ON, Canada., O'Neill P; The Canadian Medical Protective Association, Ottawa, ON, Canada., Mimeault R; The Canadian Medical Protective Association, Ottawa, ON, Canada., Garber G; The Canadian Medical Protective Association, Ottawa, ON, Canada.; Department of Medicine, University of Ottawa, Ottawa, ON, Canada.; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.; Ottawa Hospital Research Institute, Ottawa, ON, Canada.; Department of Medicine, University of Toronto, Toronto, ON Canada.
Jazyk: angličtina
Zdroj: PloS one [PLoS One] 2022 Dec 15; Vol. 17 (12), pp. e0279113. Date of Electronic Publication: 2022 Dec 15 (Print Publication: 2022).
DOI: 10.1371/journal.pone.0279113
Abstrakt: Introduction: A never event is the most egregious of patient safety incidents. It refers to events that should theoretically never happen, such amputating the wrong limb. The term "never event" is used around the world by a variety of medical and patient safety organizations and is synonymous with sentinel events and serious reportable events. Unfortunately, there is little consensus about which events, in particular, are never events. These differing lists hinder potential collaboration or large-scale analyses. A recent systematic review by Hegarty et al. (2020) identified the need for a standardized definition for serious reportable events. The objective of our systematic review is to build on this by identifying which events are consistently or frequently identified as never events in order to isolate those which are core never events.
Materials and Methods: A systematic review will be conducted using Medline, Medline in Process, Scopus, PsychINFO, Embase via OVID, and CINAHL via EBSCO databases, as well as grey literature. We will include articles of any study design that discuss never events or one of its synonymous terms in the context of medical care. Four independent reviewers will conduct the title and abstract as well as the full-text screening, and 2 reviewers will abstract data. Data will be analyzed using narrative synthesis. Results will be categorized by year and geographic location, and by other factors determined during full-text screening.
Discussion and Conclusion: The lack of consensus regarding never events hinders progress in reducing their occurrence. Differing data sources makes comparison challenging, and limits the ability for patient safety groups to work collaboratively and share learnings with others. Identifying a core set of never events will serve as a first step to focus our efforts to reduce these harmful incidents.
Competing Interests: The authors have declared that no competing interests exist.
(Copyright: © 2022 Zaslow et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)
Databáze: MEDLINE
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