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  • Proximie: Patient safety in surgery – the urgent need for reform (16 January 2022)

    • UK
    • Reports and articles
    • Pre-existing
    • Original author
    • No
    • Proximie
    • Health and care staff, Patient safety leads


    This report considers the number of safety incidents in surgery occurring in the NHS since 2015 and calls for action to improve surgical safety. It also highlights the perceptions of patients from a survey of people who have had surgery in the last five years. It is authored by surgical care platform Proximie, with support from experts in the surgical space.


    The report highlights that, based on analysis of NHS data, there has been a 30% increase in the number of patient safety incidents in surgery – instances that did or could have led to injury or death – since 2015. The analysis also shows that there were 407 ‘Never Events’ in the last year, with no reduction in the number of these incidents since 2015.

    The report includes results from a survey of 1,500 people who have had surgery in the last five years, with more than three quarters (76%) of the patients surveyed reporting safety concerns during the surgery process. Of those who were worried about their safety:

    • 17% said that their concerns were caused by not having the opportunity to ask questions.
    • 15% said their fears were caused by inconsistent information that they were given by the medical professionals they spoke to.

    12% said their worries were driven by their surgical team seeming disorganised, rushed, or tired.


    To address some of these challenges, the report details seven key recommendations to the NHS to help to change trajectory and improve patient safety in surgery:

    1. Set the safety bar higher by creating new statutory policies that ensure surgical teams adhere to guidance.
    2. Improve the standard of data available from the operating theatre so that healthcare leaders can better understand the drivers of poor patient safety and plan strategies for improvement.
    3. Create a culture of continuous learning by giving surgeons of all levels access to procedure, performance, and operating room data, allowing them to review and improve their performance.
    4. Learn from when things go well to improve patient safety and help prevent ‘Never Events’ by improving data collection, enabling systems and teams to review how and when mistakes are prevented or made.
    5. Engage with patients, ensuring that their needs are reflected in policies and processes and facilitating shared decision makers.
    6. Improve the culture within the multi-disciplinary team (MDT), so that medical professionals of all levels are empowered to question and challenge decision making during the surgical process.
    7. Increase funding for innovation, allowing surgery teams and departments to work at the top of their skillset, bolstered by innovative technological solutions.

    Patient Safety Learning Comment

    Commenting on the publication of this report, Helen Hughes, Chief Executive of Patient Safety Learning, said:

    “Too often patients are injured or die as a result of avoidable harm during surgical procedures. As this new report highlights, we need system-wide change to improve patient safety. Patient Safety Learning believes that patient engagement throughout the surgical process is key to making improvements, but there is significant work needed in this respect, particularly in relation to patients not having the opportunity to ask questions and being provided with inconsistent information prior to operations.

    “While there are new initiatives and projects underway aimed at improving surgical safety, such as ongoing work to revise the National safety standards for invasive procedures (NatSIPPs), more needs to be done to ensure we are consistently learning from patient safety incidents in surgery and use insights from these events to prevent future harm. As well as taking a huge physical and emotional impact on those affected and their families, poor patient safety also comes at a significant financial cost and undermines trust in the healthcare system.”

    Proximie: Patient safety in surgery – the urgent need for reform (16 January 2022) https://www.patientsafetywhitepaper.com/
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