Call for action following latest 'Never Events' report

The Association for Perioperative Practice (AfPP) is calling for action to be taken after a recent report suggests little progress has been made to prevent errors within the perioperative environment.

The patient safety charity made the call following the release of NHS Improvement’s latest Never Event report; Provisional publication of Never Events reported as occurring between 1 April and 31 December 2019, which revealed an alarming 81% (284) of the never events recorded happened while a patient was on the operating table.

Lindsay Keeley, patient safety and quality lead at AfPP said: “The survey highlighted that there’s a need to take action now if we are to support the healthcare profession in reducing the occurrence of never events. It has become clear that receptive team culture, a strong leadership team and better support for staff is what will help to reduce the risk of a never event occurring. It’s vital that those in leadership positions begin to understand the contributory factors in the recurrence of never events and the challenges faced by staff."

She went on to highlight some of the recent initiative taking place: “What is promising is that there are practitioners who are developing new, practical and simple solutions every day that can support other team members and can be used within theatres across the country."

"One example is Rob Tomlinson’s introduction of the 10,000 Feet initiative – a safety initiative designed to cut through noise and distraction within the theatre environment, particularly at critical points of the patient’s journey. If correctly implemented, initiatives like this can cut through the hierarchies that stop people feeling unable to speak up when they see something that shouldn’t be happening, thus reducing the occurrence of never events"

“We of course need to be mindful that there will always be challenges within perioperative practice in the form of interruptions and distractions, but the key is how as practitioners we engage with this to recognise and reduce never events.”

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Source: Clinical Services Journal, 25 February 2020