HSIB investigation: Wrong site surgery - wrong tooth extraction (22 April 2021)

Summary

This Healthcare Safety Investigation Branch (HSIB) report highlights a gap between the NHS and other safety-critical industries in identifying and managing barriers to reduce the risk of serious incidents occurring.

Content

The gap was illustrated through an investigation that focused on a case of wrong tooth extraction. Wrong tooth extraction was categorised as a Never Event and therefore HSIB sought to understand the ‘barriers’ that exist in the pathway of care for wrong tooth extraction.

The report identifies that while there are controls in place to prevent wrong tooth extraction, they invariably rely on staff to be effective and should not be regarded as ‘strong systemic protective’ barriers. The investigation went further to examine the differences in how the NHS defines and assures barriers in comparison to other safety-critical industries such as oil, gas, nuclear and aviation. The report sets out that in healthcare, the term ‘barriers’ is used generically to refer to measures put in place to prevent the occurrence of patient safety incidents. In other industries, the term is well-defined and has a specific meaning.

Section Four of the report focused on Barrier Management – the process of ensuring that safety controls are robust enough to protect against serious adverse events and their consequences. One of the investigation’s key findings is that whilst most safety critical industries have invested heavily in systems, often mandated by regulatory bodies, for identifying, analysing and assuring barriers, the NHS has not.

Another key finding in the report is that the description of what constitutes ‘barriers’ is not clearly defined in the NHS Never Events policy and framework and is inconsistent with other literature. As a result, one recommendation has been made to NHS England and NHS Improvement to review and ‘explicitly define’ what can be considered a ‘strong systemic protective’ barrier. This recommendation aligns with the findings and recommendations of the Never Events National Learning Report published in January 2021.