RESUMO
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.