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Quality improvement project to eliminate the occurrence of never events during insertion of intrauterine contraception

AIM: This project aimed to reduce the occurrence of never events during insertion of intrauterine contraception (IUC), within Central North West London NHS Foundation Trust (CNWL) clinics, to zero within 6 weeks. BACKGROUND: CNWL provides sexual health services in seven London boroughs and Surrey. A...

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Detalles Bibliográficos
Autores principales: Power, Jo, Jungmann, Eva, Rayan, Anshu, Battison, Teresa, Edwards, Simon
Formato: Online Artículo Texto
Lenguaje:English
Publicado: BMJ Publishing Group 2020
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7745678/
https://www.ncbi.nlm.nih.gov/pubmed/33328316
http://dx.doi.org/10.1136/bmjoq-2019-000819
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author Power, Jo
Jungmann, Eva
Rayan, Anshu
Battison, Teresa
Edwards, Simon
author_facet Power, Jo
Jungmann, Eva
Rayan, Anshu
Battison, Teresa
Edwards, Simon
author_sort Power, Jo
collection PubMed
description AIM: This project aimed to reduce the occurrence of never events during insertion of intrauterine contraception (IUC), within Central North West London NHS Foundation Trust (CNWL) clinics, to zero within 6 weeks. BACKGROUND: CNWL provides sexual health services in seven London boroughs and Surrey. Approximately 5500 IUC are inserted annually. Over a period of 67 days between 7 December 2017 and 12 February 2018, three incidents were identified within CNWL involving the insertion of an intrauterine contraceptive that was different to that agreed with the patient. Several different types of IUCs are available, avoiding insertion of an incorrect IUC device is important as it could lead to unwanted side effects and swapping to the chosen device could lead to a repeat procedure with potential increased risks of infection and uterine perforation. Insertion of an incorrect IUC has been classified as a never event since January 2018 when NHS Improvement updated their never events list to include ‘insertion of an IUC different from the one in the procedural plan’. Never events are serious incidents that are preventable if appropriate systems are in place. There is currently no national guidance on how to reduce the risk of IUC never events but since inclusion of IUC events in the never event list the Faculty of Sexual and Reproductive Health has been working to produce national guidance for safety standards for IUC insertion. In the interim, CNWL undertook a review of their local policies. INVESTIGATION AND RECOMMENDATIONS: Following the CNWL IUC never events, a root cause analysis investigation was conducted. A multidisciplinary team was convened to identify potential contributory factors. The main cause was identified as the lack of a standard process for confirming, documenting and double-checking the chosen IUC immediately prior to insertion. Other contributory factors included storage of similar IUC devices alongside each other and delayed access to a trained assistant in IUC clinics. Quality improvement (QI) methodology was used to help implement local system changes to reduce the risk of future errors. These included changes to IUC storage and the introduction of an IUC checklist to confirm the chosen device type during IUC insertions. RESULTS AND CONCLUSION: Since implementation of these changes 30 months ago there have been no further IUC never events within CNWL. QI methods have facilitated the successful introduction of local system changes that have reduced the occurrence of errors during IUC insertion.
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spelling pubmed-77456782020-12-28 Quality improvement project to eliminate the occurrence of never events during insertion of intrauterine contraception Power, Jo Jungmann, Eva Rayan, Anshu Battison, Teresa Edwards, Simon BMJ Open Qual Quality Improvement Report AIM: This project aimed to reduce the occurrence of never events during insertion of intrauterine contraception (IUC), within Central North West London NHS Foundation Trust (CNWL) clinics, to zero within 6 weeks. BACKGROUND: CNWL provides sexual health services in seven London boroughs and Surrey. Approximately 5500 IUC are inserted annually. Over a period of 67 days between 7 December 2017 and 12 February 2018, three incidents were identified within CNWL involving the insertion of an intrauterine contraceptive that was different to that agreed with the patient. Several different types of IUCs are available, avoiding insertion of an incorrect IUC device is important as it could lead to unwanted side effects and swapping to the chosen device could lead to a repeat procedure with potential increased risks of infection and uterine perforation. Insertion of an incorrect IUC has been classified as a never event since January 2018 when NHS Improvement updated their never events list to include ‘insertion of an IUC different from the one in the procedural plan’. Never events are serious incidents that are preventable if appropriate systems are in place. There is currently no national guidance on how to reduce the risk of IUC never events but since inclusion of IUC events in the never event list the Faculty of Sexual and Reproductive Health has been working to produce national guidance for safety standards for IUC insertion. In the interim, CNWL undertook a review of their local policies. INVESTIGATION AND RECOMMENDATIONS: Following the CNWL IUC never events, a root cause analysis investigation was conducted. A multidisciplinary team was convened to identify potential contributory factors. The main cause was identified as the lack of a standard process for confirming, documenting and double-checking the chosen IUC immediately prior to insertion. Other contributory factors included storage of similar IUC devices alongside each other and delayed access to a trained assistant in IUC clinics. Quality improvement (QI) methodology was used to help implement local system changes to reduce the risk of future errors. These included changes to IUC storage and the introduction of an IUC checklist to confirm the chosen device type during IUC insertions. RESULTS AND CONCLUSION: Since implementation of these changes 30 months ago there have been no further IUC never events within CNWL. QI methods have facilitated the successful introduction of local system changes that have reduced the occurrence of errors during IUC insertion. BMJ Publishing Group 2020-12-16 /pmc/articles/PMC7745678/ /pubmed/33328316 http://dx.doi.org/10.1136/bmjoq-2019-000819 Text en © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
spellingShingle Quality Improvement Report
Power, Jo
Jungmann, Eva
Rayan, Anshu
Battison, Teresa
Edwards, Simon
Quality improvement project to eliminate the occurrence of never events during insertion of intrauterine contraception
title Quality improvement project to eliminate the occurrence of never events during insertion of intrauterine contraception
title_full Quality improvement project to eliminate the occurrence of never events during insertion of intrauterine contraception
title_fullStr Quality improvement project to eliminate the occurrence of never events during insertion of intrauterine contraception
title_full_unstemmed Quality improvement project to eliminate the occurrence of never events during insertion of intrauterine contraception
title_short Quality improvement project to eliminate the occurrence of never events during insertion of intrauterine contraception
title_sort quality improvement project to eliminate the occurrence of never events during insertion of intrauterine contraception
topic Quality Improvement Report
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7745678/
https://www.ncbi.nlm.nih.gov/pubmed/33328316
http://dx.doi.org/10.1136/bmjoq-2019-000819
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