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  • Why are intra-operative surgical Never Events still occurring in NHS operating theatres?

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    • Nigel Roberts
    • 02/09/22
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    Summary

    In this blog, Nigel Roberts, who is a registered Allied Health Professional theatre lead at the University Hospitals of Derby and Burton (which has in excess of 50 operating theatres and performs over 50,000 procedures annually), considers the current challenges facing all operating theatre staff post pandemic. Nigel looks at how human factors may influence the delivery of the surgical safety checklist, and discusses whether Local Safety Standards for Invasive Procedures (LocSSIPs) are making a difference in terms of the number of intra-operative Never Events being reported.

    Content

    The World Health Organization (WHO) introduced the surgical safety checklist in 2009 after a successful trial in eight pilot countries; the term ‘Never Event’ has been in existence since 2001.[1] NHS England defines a Never Event as;

    Serious incidents that are entirely preventable because guidance of safety recommendations providing strong systematic barriers are available at a national level and should have been implemented by all healthcare providers.

    The current list of Never Events still only classes three reportable intra-operative ‘Never Events’: wrong site surgery, wrong implant and retained foreign object post-procedure.

    My question is why only three, what about surgical fires or wrong level spinal surgery?

    NHS Resolution reported that £13.9 million has been paid out in damages and legal costs for 459 cases relating to clinical negligence caused by surgical burn.[2] That’s an average of £30,000 per claimant.

    With wrong site surgery there has been a gradual increase in the cases reported. In March 2013, 83 cases were reported and by March 2020 this had increased to 226 cases. Wrong implant is a similar story; in March 2013, 42 cases were reported and by March 2020 this had slightly increased to 47.

    A positive piece of news is that retained foreign object post-procedure has been on the decline over the same reporting time period. In March 2013, 130 cases were reported and by March 2020, 101 cases were reported. However, there is a financial cost to both the organisation and the NHS as a whole, and a psychological life-long cost to the patient of having to have revision surgery to remove the object. The cost to the NHS between 2015 and 2020 for 389 claims was £12,472,347. That’s an average of £32,000 per claimant.

    If you add the surgical fires and retained foreign objects costs it totals £26.3 million. In today’s cost of living crisis this would give all NHS workers a good pay rise.

    Local Safety Standards for Invasive Procedures (LocSSIPs) 

    LocSSIPs was introduced in 2015 and it was anticipated that the mandatory introduction of the WHO surgical safety checklist and the refinement of the three surgical Never Events would lead to a significant reduction in their incidence in NHS England. However, a marked decrease in these Never Events was not seen and, in 2013, NHS England’s Surgical Services Patient Safety Expert Group commissioned a Surgical Never Events Taskforce to examine the reasons for the persistence of these patient safety incidents. The then Director of patient safety, Dr Mike Durkin, in 2015 stated that ”The NatSSIPs do not replace the WHO Safer Surgery Checklist. Rather, they build on it and extend it to more patients undergoing care in our hospitals”. As previously mentioned, it can be argued that the introduction of NatSSIPs/LocSSIPs, and harmonisation with the WHO checklist, to a degree, have been positive as it has led to a slight reduction in two of the three surgical never events in NHS England, but there is still much work to do.

    As part of my professional role, I undertook an audit across NHS England to ascertain if LocSSIPs were in use in all operating theatres, not other areas of a hospital where invasive procedures may be performed, for example cardiac catheter suite. Seventy-nine NHS England Trusts responded. However, six trusts stated that they had yet to implement LocSSIPs, and they had collectively reported 30 intraoperative ‘Never Events’ that had occurred between 2015 and 2020.

    There is work currently underway on NatSSIPs 2. There needs to be a real, tangible and credible drive to further reduce patient harm in the operating theatre. Never Events must be published and reported more widely to the public so patients can make a choice and NHS Trusts that have yet to implement LocSSIPs must be held to account.

    Human factors

    This brings me on to human factors. As before, an audit was carried out across NHS England. This time 57 responses were received. The largest contributory factor as to why the surgical safety checklist does not get completed was down to culture and the second was staff attitude. Leadership, communication, situational awareness and teamwork were also raised.

    There was also a clear North/South divide. The majority of the answers from the North of England stated staff attitude as the largest contributory factor and the South of England stated culture.

    Next steps

    To conclude, at this stage of my research, there is still much needed improvement and work to undertake. The surgical safety checklist is a credible tool that can lead to no patient harm if used correctly and in combination with LocSSIPs. The new work on LocSSIPs 2 needs to go further to address human factors in the operating theatre. However, a cultural change is needed from the top; time and regular training is needed, similar to the Crew Resource Management that was introduced into the airline industry, as there are similar attitudes present in today’s operating theatres. The NHS should take a leaf out of the aviation industry book and focus on prevention of Never Events by prompting teamwork, communication and managing workload, as opposed to creating a punitive blame culture.[3]

    The next stages of my PhD research are detailed below.

    Picture2.png.35c853857a471a7e3371203976314365.png

    If you would like to hear more on this subject, please come to the Future Surgery Show on the 15 and 16 November 2022 at the Excel Stadium in London and listen to the lecture and my PhD findings to date.

    References 

    1. Lembitz A, Clarke TJ. Clarifying "never events" and introducing "always events". Patient  safety in Surgery 2009; 3:26. Accessed 24 July 2022.

    2. Keeley L.  Surgical fires must become ‘Never Event’.  Clinical Services Journal 2020:18-20. Accessed 24 July 2022.

    3. Reed S, Ganyani R, King R, Pandit M. ‘Does a novel method of delivering the safe surgical checklist improve compliance? A closed loop audit’. International journal of surgery 2016; 32: 99-108. Accessed 24 July 2022.

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    Great points did you get to reserch the stop check processess 

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    Am really keen to read and learn more interms of solutions and training around the just culture 

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    10 hours ago, zali said:

    Great points did you get to reserch the stop check processess 

    Good morning. The primary research is commencing hopefully in October ,once I have Ethics approval from the University and IRAS. The research will be done via three Delphi rounds and Focus Groups.

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    10 hours ago, zali said:

    Am really keen to read and learn more interms of solutions and training around the just culture 

    Good morning,

    The training is something that I feel should be done and be mandated from NHSE/I. The CRM training worked in aviation, and this style of training must be replicated annually across the NHS

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    Thankyou robert please keep me posted  if you can 

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