Reducing harm from never events

Our work is solution focused, addressing some of the most intractable safety problems.

Over the last 15 years we have led work to reduce the occurrence of never events that are the result of poorly designed processes or equipment.

Misconnection errors involve the administration of drugs via the wrong route. For example, the injection of a toxic drug into the spine which should only be injected into a vein. Following a death in 2001 and 13 others in the UK over the previous 15 years, work began to find an engineered solution to misconnection errors. We (Lawton, Gardner and colleagues) evaluated the usability and acceptability and explored the implementation of these different engineered solutions. This research was the basis for UK National Patient Safety Agency policy and was used by companies to inform the design of these new devices.
Ultimately, this research has led to the production of safer devices that are now being purchased by NHS Trusts to reduce patient risk.

Misplaced nasogastric tubes are a serious never event resulting in 21 deaths in the UK (2005-2011). Lawton and the team developed interventions to change practice (e.g. point-of-care instructions distributed with 950,000 NG tubes) but the process was still far from failsafe, so they explored alternatives. The University of Leeds Innovation team introduced them to a group of scientists (Roboscientific) who were using volatiles to develop smell-fingerprints for a variety of agri-food (e.g. food storage) purposes. Lawton and her team identified this as a potential method for ensuring accurate placement of NG tubes. Having proved this concept (2016-18) they were awarded a £1 million MRC grant (2019-2022) to develop, and do first in man testing of, a new device (NG-Sure). Confidentiality issues have precluded publication of this work to date. The team have now developed a sensor array (2020) to distinguish lung and stomach smell-fingerprints and are currently working with users
(including carers) to design the diagnostic device, which will be ready for testing in 2022.

We will continue to develop these solutions (we are currently working on Guidewire retention never events) within the broader Yorkshire and Quality Safety Research Group (YQSR). The work within the NIHR Yorkshire and Humber PSRC will generate ideas for intractable problems that can be addressed in collaboration with this larger group (YQSR).

References

Lawton et al., 2009: https://qualitysafety.bmj.com/content/18/6/492.short

Lawton et al., 2007: https://www.researchgate.net/profile/Rebecca-Lawton-5/publication/266473935_PS049_Pre-Implementation_Evaluation_of_Non-Luer_Compatible_Spinal_Equipment/links/552e5f510cf22d43716e18ee/PS-049-Pre-
Implementation-Evaluation-of-Non-Luer-Compatible-Spinal-Equipment.pdf

Grange et al., 2019: https://yqsr.org/our-research-programmes/volatile-biomarker-positioning-of-naso-gastric-tubes-to-enhancepatient-safety-acronym-ng-sure/