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

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.

theatre staff globally.Improving preoperative planning and using surgical check list can reduce wrong site surgery. 6,7Despite this, surgical specialities contribute significantly to the overall burden of NEs. 4 To date, no publications have addressed the burden of NEs in urology in the United Kingdom or internationally.This is despite the potential of NEs to cause major patient harm; indeed, NEs result in death in up to 20% of cases. 8Furthermore, £74.5million was paid by the NHS over a 20-year period as a result of litigation claims relating to urology. 9e aim of this study was to assess the prevalence of NEs specific to urology in the United Kingdom and to identify relevant themes that may help to mitigate their occurrence in future.

| METHODS
It is mandatory to report all NEs within the UK NHS via the National There have been several changes made to the NEs reporting process.In 2015, the NE policy and framework were changed, and the definition of an NE changed to include all cases with potential to cause harm/death as opposed to actual harm.The reports for April 2018 to March 2019 and 1 April 2020 to 31 March 2022 were still provisional reports, which were yet to be finalised at the time of data collection.Furthermore, the way NEs are to be reported is also due to change.A new system, Learn from Patient Safety Events (LFPSE), was introduced in 2021, which is intended to replace the NRLS by September 2023.These factors prevented effective year-on-year comparison of NEs, and thus, this was not attempted.Data regarding the total number of urology procedures performed in the same time period (2012-2022) in England were obtained via NHS digital's Hospital Episode Statistics. 10 Urology procedures were identified using codes for urinary (M01-M86) and male genital organs (N01-N35).

| RESULTS
A total of 3972 NEs were reported between 2012 and 2022.Of these, 3167 (79.7%) were procedural/surgical related.Urology-specific NEs comprised 95 events (2.4%) and are detailed in Table 1.
NEs displayed by year reported are included in Figure 1.
The most common surgical intervention associated with a urological NE was ureteric stenting, which comprised 45/95 (47.4%) of all analysed NEs.The most common NEs were both stent related: wrong site ureteric stent insertion (n = 29; 30.5%) and wrong site ureteric stent removal (n = 9; 9.5%).There were also two retained guidewires used in ureteric stenting and five wrong type of stents used.
T A B L E 1 Urology-specific never events.

| DISCUSSION
We identified 95 NEs in the NHS relating to urology between 2012 and 2022, representing 0.0013% of all urological procedures.There has been a notable increase in NE reported comparing pre-2015 and post-2015 (Figure 1).This is likely due to changes made in 2015 in which a more robust process was introduced by NHS England in an effort to standardise and increase reports of NEs. 7 A similar study of patients over a 9-year period identified 797 NEs in general surgery, a higher number than our study.However, this study included generic NEs such as retained surgical swabs, wrong finger surgery and cervical biopsies; this may account for the differential NE rates. 5In contrast, a study of trauma and orthopaedic surgery NEs that restricted analyses to trauma and orthopaedic-specific outcomes identified 460 NEs between 2012 and 2020, the most common of which were wrong implant/prosthesis (206/460) followed by wrong site surgery (197/460). 10Considering a total of 7.81 million trauma and orthopaedic procedures over this time (based on NHS Digital data), this represents 0.01% of all cases; an NE rate significantly higher than that of urology NEs (chi-squared p < 0.001).These higher rates may be due to the increased risk of error when dealing with multiple limbs and digits as opposed to the renal system.
In our data, urology-specific NEs comprised 2.4% of the total number of NEs reported during the study period.The most common type of urology NE identified was wrong site surgery, representing 65/95 (68.4%) of urological NEs.Precautionary principals have been made available including the WHO 'Safe Surgery Checklist' that aim to facilitate safe operative practices and prevent wrong site surgery and retained foreign bodies.However, a number of studies have demonstrated that NEs continue to occur. 4,8,9Practices such as utilising radiopaque markers to indicate surgical side, for example, an ECG lead sticker, rather than relying on pen markings that are frequently covered by sterile drapes, may reduce the incidence of wrong site surgery. 6Coloured markers on the distal portion of ureteric stents could be introduced to indicate 'left' and 'right' to help prevent removal stents from the wrong side.
Human factors and ergonomics (HFE) is a scientific discipline that seeks to understand interactions between human behaviour and system safety. 10It is estimated that 80% of errors in the NHS are attributable to human factors at an individual or organisational level. 11In 2018, the Care Quality Commission (CQC) reported on NHS safety culture after visiting 18 trusts between April and June 2018 and holding focus groups with patients, staff and experts to investigate the potential contributors to NEs in the NHS.It was estimated that 96% of NEs reported in the year prior to the report should have been preventable with regular actions by humans. 12Global data have identified sources of general error in operating theatres to include human fallibility, miscommunication, lack of team activity, human-technology interaction and poor management of the environment. 2,3This can be further exacerbated by poor concentration due to increased workload and long working hours. 2 These errors can lead to non-adherence to the protective mechanisms in place to prevent NEs, such as site marking or adherence to the WHO safety checklist. 13Further, in the NHS, it is common with pooled waiting lists that a surgeon examining a patient in the outpatient clinic will be different to the surgeon performing the operation at a later date.Though data are not available on F I G U R E 1 Urology-specific never events by year reported.
the impact of this on NE frequency, it is possible that the time between booking and surgery, and the change in medical staffing, may have an impact. 14recent literature review of NEs in surgery worldwide concluded that an efficient system allowing error reporting, learning from incidents and sharing of information would likely improve patient safety. 2 Simulation sessions may also allow testing of teamwork under different pressures allowing identification of possible points of error.
There are a number of contributing factors to risk of NE occurrence that is not available in the NE database or in the literature and may warrant further investigation.It is well established that emergency surgery is associated with an increased rate of morbidity and mortality compared with elective surgery; however, the comparative rate of NEs in these two settings is not yet known or available. 15ere may also be a link between rate of NE and time of surgery (within normal working hours vs outside of these hours), and these fields could be included in the NE reporting tool to improve data granularity.There may be a link between grade of surgeon, level of supervision (whether a trainer was scrubbed, unscrubbed but present the theatre suite or not present) and risk of NEs.There are a number of collaborative studies including the grade of primary surgeon that are ongoing and may identify a link with surgical outcome. 16,17Currently, there are no data available regarding grade of surgeon and risk of an NE.When considering reporting tool design, it is important to take account of burden on those uploading data to increase compliance; however, there may be value in including additional fields in the reporting tool, such as time of surgery, nature of surgery (elective vs emergency), surgeon grade, level of supervision and reporting specialty.Acquisition of this data would enable analyses that may allow organisations to direct efforts to reduce NEs.This would also allow attribution of 'generic' NEs such as non-procedural NEs (e.g.drug errors) to the reporting specialty.
NHS England does not specify the specialty reporting each NE.We have therefore not included generic NEs such as retained swabs that may have been reported by urology, as we are unable to confirm the proportion of which are from urological procedures.This is a limitation of this study as the overall NE count could be significantly underestimated.We suggest that an improvement to the NHS database would be to include the reporting specialty within the database as this will allow identification of those specialties that may benefit from new interventions in an effort to reduce NEs.
Reporting and Learning System (NRLS) and Strategic Executive Information System (StEIS).NHS England collects the data and produces a yearly report for all NEs occurring in England.The NEs are classified according to various categories including wrong site surgery, retained foreign object post-procedure and wrong implant/prosthesis.These are then subdivided into more specific categories.All NEs on the NHS England database from 2012 to 2022 were analysed by a focus group of surgical trainees.This database covers NEs occurring in England, excluding Wales, Scotland and Northern Ireland.Urology-specific NEs such as 'wrong side ureteric stent' or 'cystoscopy intended for another patient' were identified from the sub-categories listed in the database.These urology-specific NEs were reviewed and recommendations made under the supervision of a urology consultant.