Reviewing ‘work as done’ to prevent wrong site anaesthetic blocks: An interview with Marsha Jadoonanan, HCA Healthcare UK

Summary

Marsha Jadoonanan, nurse and Head of Patient Safety and Learning at HCA Healthcare UK (HCA UK), spoke to us about a recent opportunity to learn from patient safety incidents involving wrong site anaesthetic blocks. She describes the new learning approach she and her colleagues used, which focused on engaging staff working in a variety of roles to create a safe space to focus on identifying ‘work as done’.

About the Author

Marsha Jadoonanan is Head of Patient Safety and Learning at HCA Healthcare UK and has been a registered nurse for over twenty years.

Questions & Answers

Hi Marsha, can you tell us a little bit about yourself and what your current role involves?

I’m Marsha Jadoonanan and I’ve been Head of Patient Safety and Learning at HCA Healthcare UK since February 2023. I’ve been a registered nurse for over twenty years and that clinical experience enhances my role as a patient safety specialist. My new role has been very interesting working on several patient safety improvement projects and particularly with the launch of the Patient Safety Incident Response Framework (PSIRF).

You have recently reviewed your ways of working to improve safety in surgery- can you tell us what happened?

When a patient comes in for surgery, the surgeon will use a pen to make a surgical site mark on the body to indicate where they will operate. For example, if you come in for an operation on your right wrist, the surgeon would clearly mark your right wrist. If the patient requires a local anaesthetic block, it’s also important that the anaesthetist has a way of ensuring they apply the block to the correct part of the body. We have seen variation in practice in this area that can lead to selection of the wrong site, as the site where a block should be applied is not always clearly identified.

 We realised we needed to look closely at our practice and consider what other systemic safety measures we could put in place to reduce the chance of it happening. We wanted to make sure that there are very clear work procedures for all stakeholders involved in the process of anaesthetic blocks, so that everyone understands when the site is identified, who is responsible for the check and how they proceed to the next phase.

How did you ensure you took relevant learning from existing practice?

Any incident goes through our normal incident investigation process, but for the learning aspect we decided to try a new approach. We started the process by inviting subject matter experts from a range of roles in different specialities across the organisation to an online seminar to discuss how we could make anaesthetic blocks safer. It was a useful conversation that helped us understand a range of viewpoints that different stakeholders had and to get some insights of techniques that had worked elsewhere. 

Following on from this seminar, we formed a safety improvement working group consisting of operational staff who carry out this procedure to really explore ‘work as done’. We needed to understand the real context of how these procedures are actually performed and the sequence in which they done in order to look at where we could enhance the safety checks involved. We looked at where there could be different interpretations of the steps in the standard checking pathway. We then mapped out the patient pathway using lots of different tools including observation, piloting, testing and mocking up scenarios. 

The ‘Prep Stop Block’ approach is national policy used to promote safety in anaesthetic blocks. We looked at the guidance and literature around this process and found that much of it didn’t emphasise the ‘stop’ moment, and that by reinforcing the ‘stop’ moment, provided an opportunity to repeat the site check. We identified this as the area where we needed to introduce more controls, so we looked at the literature around how people were best reinforcing the ‘stop’ moment. We then proposed and piloted two different ways to do this. We used the feedback from the pilots to inform an options analysis that we presented to HCA UK’s Anaesthetic Council, who would review our work and make the final decision about how to best move forward. 

The solution that we recommended was the introduction of a physical locked box (like a sealed container) to contain the equipment needed for the block. The box helps physically empower our ODP’s and remains within their ‘control’ until the anaesthetist has prepped. At this point, both the anaesthetist and ODP will check that the right site has been identified before the ODP hands over the block equipment. The Anaesthetic Council agreed that this approach should be adopted to ensure the ‘stop’ moment robustly takes place. 

How will you go about implementing the boxes across the organisation?

We’re reengaging the working party to create a short training video which will run through this new process. We’ll share it through a variety of channels including posters and having our clinical practice educators walking around to talk staff through the process and allow them to ask questions. Before that however we are working on engaging staff on the reasons for this change and will phase the rollout, so we listen and work with the staff who do this work on a day to day basis. We have also changed our Standard Operating Procedure documentation and surgical checklist to reflect these new steps. 

We’re collecting early feedback and will audit the implementation through a simple survey for anaesthetists and theatre staff. We really want to understand whether the box is enforcing the stop moment for different staff and whether they see any areas where we could further improve the process. We’re also going to be asking about whether there are any other factors that we need to address if they are affecting implementation. One question will be simply, “Are you aware of this new process?” because we also need to check whether our communications were effective. In time, we will do a formal audit of the new process.

What are your reflections on the approach you took?

What stood out to me is that when we had the original seminar, which was mostly attended by anaesthetists, the response in the room that kept coming up was “we should mark the site.” When we went out and looked at the research and observed ‘work as done’, the solution we proposed was very different to what came out of the initial seminar. I realised that what we got from the seminar (apart from engagement on this subject) was ‘work as imagined’—most people in the room were not considering the real-life factors that apply in the operating theatre environment. That’s what we got from talking to and observing theatre staff doing this procedure.

If we hadn’t engaged with and involved the stakeholders that we did, we would have gone ahead and implemented an intervention around marking the site. There’s a lot of evidence that shows that marking the site is one of the least effective things you can do as a single intervention. Because we gained an understanding of ‘work as done’, we knew that staff would find it hard to just change practice, and therefore such an intervention was unlikely to be effective. 

How will you use what you’ve learned as you take PSIRF forward?

It was good to hear the voice of colleagues involved and a helpful reminder that we need to move from making decisions based on ‘work as imagined’ to making them based on ‘work as done’, which is a key underpinning part of the PSIRF approach. 

PSIRF provides us with a range of tools and a structure to examine how work is done within a system. It’s a change in mindset, and hopefully will bring about effective change and sustainable improvements going forward. Let’s get out there and speak to colleagues; what I’ve seen is that they feel empowered by being included in the process and having their insights considered. The people in our working group are proud of what they’ve achieved in bringing in an intervention that they believe is going to work.

We finally have a structure to work within where we can shift our attention from the endless report writing to focus on examining the system and making meaningful change to improve patient safety. The learning response tools provide a powerful opportunity to see themes and trends, and to understand the blockers that individuals have to work around because they are out of their control. 

Related reading

• Putting the writing on the wall: Explaining work as imagined vs work as done (by Claire Cox)
• Patient Safety Spotlight Interview with Judi Ingram, Vice President of Quality for HCA Healthcare UK and Patient Safety Learning Trustee