Links-Rechts-Verwechslungen und andere Never Events in der Gesundheitsversorgung

Trotz verschiedener Maßnahmen zur Verhinderung von Never Events – schwerwiegende, vermeidbare medizinische Ereignisse – treten diese weltweit weiterhin auf. Dieser Übersichtsartikel gibt einen Überblick darüber, wie grundlegende Themen der neuropsychologischen Forschung wie Handlungsüberwachung und kognitive Kontrolle, Fehlerverarbeitung, Aufmerksamkeit und Gedächtnis von höchster Relevanz für das Verständnis der Entstehung von Never Events und ihrer Prävention sind.

Kernaussagen

• Never Events in der Gesundheitsversorgung sind vollständig vermeidbare, schwerwiegende Vorfälle in Institutionen des Gesundheitswesens, bei denen es zu Schädigungen von Patientinnen oder Patienten bis hin zum Tod kommt.

• Links-Rechts-Verwechslungen gehören zu den häufigsten Never Events in Operationssälen weltweit.

• Trotz verschiedener Maßnahmen zur Verhinderung von Never Events treten diese weltweit weiterhin auf.

• Grundlegende Themen der neuropsychologischen Forschung wie Handlungsüberwachung und kognitive Kontrolle, Fehlerverarbeitung, Aufmerksamkeit und Gedächtnis sind von höchster Relevanz für das Verständnis der Entstehung von Never Events und ihrer Prävention, werden jedoch bisher nur unzureichend in der Forschung zu Never Events und ihrer Prävention berücksichtigt.

• Kenntnisse des neuropsychologischen Hintergrunds verschiedener Never Events haben eine hohe Relevanz für die klinische Praxis und können Konzepte zur Verringerung von Never Events darstellen.

Schlüsselwörter

Patientensicherheit - Fehlermanagement - Qualitätsmanagement - unerwünschtes Ereignis

Publication History

Article published online:
03 December 2024

• Literatur

• 1 Flug JA, Ponce LM, Osborn HH. et al. Never events in radiology and strategies to reduce preventable serious adverse events. Radiographics 2018; 38: 1823-32
• 2 Koleva SI. A literature review exploring common factors contributing to Never Events in surgery. J Perioper Pract 2020; 30: 256-64
• 3 Petzina R, Wehkamp K. Qualitätsmanagement und Qualitätssicherung im Gesundheitswesen. In: Haring R. Gesundheitswissenschaften. Berlin, Heidelberg: Springer; 2022: 1-16
• 4 Power J, Jungmann E, Rayan A. et al. Quality improvement project to eliminate the occurrence of never events during insertion of intrauterine contraception. BMJ Open Qual 2020; 9: e000819
• 5 Kizer KW, Stegun MB, Henriksen K. et al. Serious reportable adverse events in health care. Advances in Patient Safety: From Research to Implementation (Volume 4: Programs, Tools, and Products). Rockville (MD): Agency for Healthcare Research and Quality (US); 2005
• 6 Omar I, Singhal R, Wilson M. et al. Common general surgical never events: analysis of NHS England never event data. Int J Qual Helath Care 2021; 33: mzab045
• 7 Bowman CL, Gorter R de, Zaslow J. et al. Identifying a list of healthcare 'never events' to effect system change: a systematic review and narrative synthesis. BMJ Open Qual 2023; 12: e002264
• 8 Gormley GJ, Dempster M, Corry R. et al. ‘When right could be so wrong’. Laterality errors in healthcare. Ulster Med J 2018; 87: 3-10
• 9 Marung H, Moecke H, Poloczek S. et al. Never events: building a consensus on patient safety in prehospital emergency care. Resuscitation 2015; 96: 122-3
• 10 Marcus SC, Hermann RC, Cullen SW. Defining patient safety events in inpatient psychiatry. J Patient Saf 2021; 17: e1452-e1457
• 11 NHS. The financial costs of Never Events to hospital trusts of Never Events. The costs of incivility in Operating Theatres throughout the NHS, if any? Freedom of Information Request. 2020 Accessed March 24, 2024 at: https://resolution.nhs.uk/wp%20content/uploads/2021/01/FOI_4850_Never-Events.pdf
• 12 Wu RL, Aufses AH. Characteristics and costs of surgical scheduling errors. Am J Surg 2012; 204: 468-73
• 13 Kjellberg J, Wolf RT, Kruse M. et al. Costs associated with adverse events among acute patients. BMC Health Serv Res 2017; 17: 651
• 14 Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ 2000; 320: 726-727
• 15 Rösner H, Raspe M, Strametz R. Second-Victim-Traumatisierungen – Auswirkungen auf Behandelnde und Patienten. OP-Management up2date 2023; 03: 141-148
• 16 Rösner H, Bushuven S, Ettl B. et al. Second Victim: Übersetzung der internationalen konsensbasierten Definition mittels Delphi-Methode. Zbl Arbeitsmed 2024; 2024
• 17 Marung H, Strametz R, Roesner H. et al. Second Victims among German Emergency Medical Services Physicians (SeViD-III-Study). Int J Environ Res Public Health 2023; 20: 4267
• 18 Coughlan B, Powell D, Higgins MF. The second victim: a review. Eur J Obstet Gynecol Reprod Biol 2017; 213: 11-6
• 19 McDaniel LR, Morris C. The second victim phenomenon: how are midwives affected?. J Midwifery Womens Health 2020; 65: 503-11
• 20 Peterburs J, Desmond JE. The role of the human cerebellum in performance monitoring. Curr Opin Neurobiol 2016; 40: 38-44
• 21 Zhang J, Patel VL, Johnson TR. et al. A cognitive taxonomy of medical errors. J Biomed Inform 2004; 37: 193-204
• 22 Eriksen BA, Eriksen CW. Effects of noise letters upon the identification of a target letter in a nonsearch task. Percept Psychophys 1974; 16: 143-9
• 23 Voegler R, Peterburs J, Lemke H. et al. Electrophysiological correlates of performance monitoring under social observation in patients with social anxiety disorder and healthy controls. Biol Psychol 2018; 132: 71-80
• 24 Rabbitt PM. Error correction time without external error signals. Nature 1966; 212: 438
• 25 Botvinick MM, Braver TS, Barch DM. et al. Conflict monitoring and cognitive control. Psychol Rev 2001; 108: 624-52
• 26 Dutilh G, Vandekerckhove J, Forstmann BU. et al. Testing theories of post-error slowing. Attent Percept Psychophys 2012; 74: 454-65
• 27 Fischer AG, Nigbur R, Klein TA. et al. Cortical beta power reflects decision dynamics and uncovers multiple facets of post-error adaptation. Nat Commun 2018; 9: 5038
• 28 Gehring WJ, Goss B, Coles MGH. et al. A neural system for error detection and compensation. Psychol Sci 1993; 4: 385-90
• 29 Falkenstein M, Hohnsbein J, Hoormann J. et al. Effects of crossmodal divided attention on late ERP components. II. Error processing in choice reaction tasks. Electroencephalogr Clin Neurophysiol 1991; 78: 447-55
• 30 Debener S, Ullsperger M, Siegel M. et al. Trial-by-trial coupling of concurrent electroencephalogram and functional magnetic resonance imaging identifies the dynamics of performance monitoring. J Neurosci 2005; 25: 11730-7
• 31 Endrass T, Riesel A, Kathmann N. et al. Performance monitoring in obsessive-compulsive disorder and social anxiety disorder. J Abnorm Psychol 2014; 123: 705-14
• 32 Hajcak G. What we’ve learned from mistakes. Curr Dir Psychol Sci 2012; 21: 101-6
• 33 Hajcak G, Moser JS, Yeung N. et al. On the ERN and the significance of errors. Psychophysiology 2005; 42: 151-60
• 34 Pailing PE, Segalowitz SJ. The error-related negativity as a state and trait measure: motivation, personality, and ERPs in response to errors. Psychophysiology 2004; 41: 84-95
• 35 Weinberg A, Riesel A, Hajcak G. Integrating multiple perspectives on error-related brain activity: The ERN as a neural indicator of trait defensive reactivity. Motiv Emot 2012; 36: 84-100
• 36 Klawohn J, Endrass T, Preuss J. et al. Modulation of hyperactive error signals in obsessive-compulsive disorder by dual-task demands. J Abnorm Psychol 2016; 125: 292-8
• 37 Steinhauser R, Steinhauser M. Adaptive rescheduling of error monitoring in multitasking. Neuroimage 2021; 232: 117888
• 38 Cavanagh JF, Frank MJ. Frontal theta as a mechanism for cognitive control. Trends Cogn Sci 2014; 18: 414-21
• 39 Cavanagh JF, Eisenberg I, Guitart-Masip M. et al. Frontal theta overrides pavlovian learning biases. J Neurosci 2013; 33: 8541-8
• 40 Ocklenburg S, Peterburs J. Monitoring brain activity in VR: EEG and neuroimaging. Curr Top Behav Neursci 2023; 65: 47-71
• 41 Lange L, Osinsky R. Aiming at ecological validity – Midfrontal theta oscillations in a toy gun shooting task. Eur J Neurosci 2021; 54: 8214-24
• 42 Haus K-M, Held C, Kowalski A. Praxisbuch Biofeedback und Neurofeedback. 2. Aufl. 2016. Berlin, Heidelberg: Springer;
• 43 Corominas-Roso M, Ibern I, Capdevila M. et al. Benefits of EEG-neurofeedback on the modulation of impulsivity in a sample of cocaine and heroin long-term abstinent inmates: a pilot study. Int J Offender Ther Comp Criminol 2020; 64: 1275-98
• 44 Horrell T, El-Baz A, Baruth J. et al. Neurofeedback effects on evoked and induced EEG gamma band reactivity to drug-related cues in cocaine addiction. J Neurother 2010; 14: 195-216
• 45 Konicar L, Veit R, Eisenbarth H. et al. Brain self-regulation in criminal psychopaths. Sci Rep 2015; 5: 9426
• 46 Wang J-R, Hsieh S. Neurofeedback training improves attention and working memory performance. Clin Neurophysiol 2013; 124: 2406-20
• 47 Enriquez-Geppert S, Huster RJ, Figge C. et al. Self-regulation of frontal-midline theta facilitates memory updating and mental set shifting. Front Behav Neurosci 2014; 8: 420
• 48 Eschmann KCJ, Mecklinger A. Improving cognitive control: Is theta neurofeedback training associated with proactive rather than reactive control enhancement?. Psychophysiology 2022; 59 (05) e13873
• 49 Hirnstein M, Ocklenburg S, Schneider D. et al. Sex differences in left-right confusion depend on hemispheric asymmetry. Cortex 2009; 45: 891-9
• 50 Hjelmervik H, Westerhausen R, Hirnstein M. et al. The neural correlates of sex differences in left-right confusion. Neuroimage 2015; 113: 196-206
• 51 Mansour S, Mwafi N, Al-Tawarah N. et al. Prevalence of left/right confusion among medical students in mutah University- Jordan. Georgian Med News 2023; 344: 85-89
• 52 Ocklenburg S, Hirnstein M, Ohmann HA. et al. Mental rotation does not account for sex differences in left-right confusion. Brain Cogn 2011; 76: 166-171
• 53 van der Ham IJ, Dijkerman HC, van Stralen HE. Distinguishing left from right: a large-scale investigation of left-right confusion in healthy individuals. Q J Exp Psychol 2021; 74: 497-509
• 54 Dyer O. Doctors suspended for removing wrong kidney. BMJ 2004; 328: 246
• 55 Pikkel D, Sharabi-Nov A, Pikkel J. "It is the left eye, right?". Risk Manag Healthc Policy 2014; 7: 77-80
• 56 Ofte SH. Right-left discrimination: effects of handedness and educational background. Scand J Psychol 2002; 43: 213-219
• 57 Ofte SH, Hugdahl K. Right-left discrimination in male and female, young and old subjects. J Clin Exp Neuropsychol 2002; 24: 82-92
• 58 Ofte SH, Hugdahl K. Right-left discrimination in younger and older children measured with two tests containing stimuli on different abstraction levels. Percept Mot Skills 2002; 94: 707-719
• 59 Gromer A, Pflüger P, Dommasch M. et al. Operationsvorbereitung in der Unfallchirurgie. Unfallchirurg 2021; 124: 839-852
• 60 Vingerhoets G, Sarrechia I. Individual differences in degree of handedness and somesthetic asymmetry predict individual differences in left-right confusion. Behav Brain Res 2009; 204: 212-216
• 61 Zejnullahu VA, Bicaj BX, Zejnullahu VA. et al. Retained surgical foreign bodies after surgery. Open Access Maced J Med Sci 2017; 5: 97-100
• 62 Reason J. Human error: models and management. BMJ 2000; 320: 768-770
• 63 Grundgeiger T, Sanderson PM, Orihuela CB. et al. Prospective memory in the ICU: the effect of visual cues on task execution in a representative simulation. Ergonomics 2013; 56: 579-589
• 64 Fencl JL. Guideline Implementation: Prevention of Retained Surgical Items. AORN J 2016; 104: 37-48
• 65 Stawicki SP, Moffatt-Bruce SD, Ahmed HM. et al. Retained surgical items: a problem yet to be solved. J Am Coll Surg 2013; 216: 15-22
• 66 Gawande AA, Studdert DM, Orav EJ. et al. Risk factors for retained instruments and sponges after surgery. N Engl J Med 2003; 348: 229-235
• 67 Nichols P, Copeland T-S, Craib IA. et al. Learning from error: identifying contributory causes of medication errors in an Australian hospital. Med J Aust 2008; 188: 276-279
• 68 Grewe P, Ohmann HA, Markowitsch HJ. et al. The Bergen left-right discrimination test: practice effects, reliable change indices, and strategic performance in the standard and alternate form with inverted stimuli. Cogn Prcess 2014; 15: 159-172