The project will draw on a wide evidence base, building on work already happening within CPOC, our partner organisations and across the entire health and care sector. We will also reach out to our community of thousands of health professionals and patients to generate new evidence that will enable us to develop future policy and make the best possible case for change.

Get involved

The Green Paper can't be delivered without the active participation and help of everyone working to deliver better patient-centred care. If you would like to get involved with this project, then please consider joining the informal ‘sounding board’ of healthcare professionals, patients, and policymakers. The kinds of things CPOC will be looking for your help with include:

• Giving your views as CPOC develop their policy thinking, e.g. by taking surveys, feeding back on draft papers or reports, testing the messaging, and helping plug evidence gaps or prioritise what CPOC explore further.
• Championing the work on social media and to your personal and professional networks.
• Blogging for CPOC to share your experiences, reflecting on new findings, and informing the public about this work.
• Attending workshops or events CPOC may host as part of the consultation work for this project.

If interested email cpocgreenpaper@rcoa.ac.uk. 

Overall, the study shows that the frequency of WSS varied according to a range of variables, including error type (e.g., wrong side, wrong site, wrong procedure, wrong patient); year; facility type; hospital bed size; hospital procedure location; procedure; body region; body part; and clinician specialty. Our findings are aligned with some of the previous research on WSS; however, the current study also addresses many gaps in the literature. We encourage readers to use the visuals in the manuscript and appendices to gain new insight into the relation among the variables associated with WSS. Ultimately, the findings reported in the current study help to convey a more complete account of the variables associated with WSS, which can be used to assist staff in making informed decisions about allocating resources to mitigate risk.

The model suggests a 71% decrease in the patient risk of surgical fires from 2005 to 2016. The analysts noted that in 2005, there was about one surgical fire per month in Pennsylvania, and, if the downward trend continues, the rate will be only one surgical fire per year in 2032.

The headline findings include:

• Revision rates have fallen every year since 2012, even while total activity and demand grows
• Average lengths of stay have been reduced by a fifth, releasing over 368k bed-days
• £696 million of operational and financial opportunities have been released to trusts

View the original GIRFT Programme National Specialty Report on orthopaedics

In total, 141 patients participated. Patients were positive towards the checklist, strongly agreeing that it would impact positively on their safety and on surgical team performance. Those worried about coming to harm in hospital were particularly supportive. Views were divided regarding hearing discussions around blood loss/airway before their procedure, supporting appropriate modifications to the tool. Patients did not feel they had a strong role to play in safety improvement more broadly.

The authors concluded that it is feasible and instructive to capture patients’ views of the delivery of safety improvements like the checklist. The study demonstrated strong support for the checklist in a sample of surgical patients, presenting a challenge to those resistant to its use.

• complications
• patient and OR readiness
• retained surgical instruments
• contamination
• equipment failures
• wrong surgery.

There are common themes echoed through each of the six event types examined in this Deep Dive. These include the following:

• Communication problems are an underlying issue. Problems with communication—whether between the scheduler and the OR team, between clinical staff and the patient, or among the OR team—can lead to adverse events or near misses.
• Organisations should promote a team approach. Taking a team approach to surgical procedures can help avoid many of the adverse events reported in this Deep Dive. Such an approach is an element of a culture of safety and should be emphasised through team-building exercises.
• Organisations should focus on addressing preventable events. Some events are not preventable, meaning that no matter how well the team prepares, the event would likely have happened anyway. For example, the patient could have an allergic reaction resulting from an unknown anesthesia allergy, or a rare but known risk of surgery occurring. Focusing on preventable events can help focus the surgical team’s attention, however, thereby reducing the risk of unpreventable events as well.
• Quality improvement should be emphasized to reduce risk. Clinical staff should apply a quality improvement mentality to any problems that emerge, and focus on actions that can be taken to prevent such problems in the future.

Key messages

• Our review found that multidisciplinary working is worth prioritising. There is evidence that in some cases multidisciplinary working can: 
• speed access to surgery, if that is an appropriate treatment option
• improve people’s clinical outcomes, such as reducing complications after surgery
• reduce the cost of surgical care by helping people leave hospital earlier

However, these benefits are not always apparent. More work is needed to explore which types of multidisciplinary working are most effective and what infrastructure and resources are needed to strengthen and sustain multidisciplinary care around the time of surgery. 

• Command
• Communications
• Capacity and resource management
• Contingency planning
• Clinical knowledge