Nigel Roberts

The PIT stop (prosthesis/implant timeout) checklist is Birmingham Women's and Children's NHS Trust's visual and aid memoir. It was launched to limit 'human error' and thus preventing never events (wrong implant/prosthesis). The four steps cover the intra-operative stages when implants are required. It works by recording what is requested on a small, hand held white board, and works in harness with the NatSSIPs 8, specifically step 5 of the infographic that has been previously developed. Download the checklist in Word from the attachment below:

This paper asked healthcare workers who are considered to be theatre safety experts—theatre managers, matrons and clinical educators—to take part in the second round of a Delphi study. These individuals work at the coalface in operating theatres and deliver the surgical safety checklist daily. It addresses information raised as part of a Delphi study of NHS hospital operating theatres in England. The aim of the second Delphi study round was to establish the views of theatre users on the theatre checklist and local safety standards for invasive procedures. Likert scale responses and a combination of closed and open-ended questions solicited specific information about current practice and researched literature that generated ideas and allowed participants freedom in their responses of how the World Health Organisation’s (WHO's) Surgical Safety Checklist (SSC) is currently being used in the peri-operative setting as part of a strategy to reduce surgical ‘never events’. The paper is part of a literature review undertaken by the author towards a Doctor of Philosophy (PhD). Read the findings of round one of the Delphi study Delphi study participants Participants were from the seven regions identified by NHS England. The study revisited several questions from round one to gather further knowledge and understanding of the responses received. The debrief was not undertaken due to all team members not being present, staff wanting to go home, current culture and list overruns. Key initial findings of Delphi study round two The second round facilitated a broader engagement in the literature, as well highlighting a number of reasons why full compliance has not yet been universally achieved. The Delphi study is intended to be an exploratory approach to inform a more in-depth doctoral research study intended to improve patient safety in the operating theatre, inform policy making and quality improvement. Participants felt that training on the checklist should be mandated and take place annually. They also felt that learning from other organisations was key, and that the NHS needs to revise how the checklist is currently being delivered by being more proactive and by providing the foundations of an electronic checklist to all NHS trusts. Participants felt that a lack of direction from senior NHS leaders and multidisciplinary team working may impact on why the checklist is not always completed. With regard to Local Safety Standard for Invasive Procedures (LocSSIPs) and their introduction, participants either strongly agreed or agreed that NHS trusts must be held accountable for ensuring they are implemented. Participants overwhelmingly felt that surgical fires (non-airway) should be classed as a Never Event. To ensure cyclical learning occurs, details of each and every Never Event should be provided to all NHS Trusts Context of the Delphi study The literature to support a greater understanding of the impact on the implementation of checklist is still emerging. The review to date is not intended to be exhaustive, but begins to frame further questions, identify some of the contextual issues and plan for the third and final Delphi round. The use of a Delphi study was born out of curiosity to see to what the theatre safety experts (matrons, managers and clinical educators) think of the current checklist since its introduction across England thirteen years ago. Contextually it can be anticipated that invasive procedures in the NHS and indeed in healthcare globally will continue to rise, in part as a result of the advancement of new supportive technologies, such as robotics and enhanced minimally invasive approaches. Furthermore, access to these treatments is more readily available to different patient groups whose needs and longer-term rehabilitation can be more complex and demanding. While in this regard clinical outcomes, quality of life, and indeed life expectancy can be improved and extended, this is only the case if surgery takes place within optimum conditions. Taking all other factors into consideration, the number of Never Events continues to remain a constant yet stubborn patient safety concern. Future work - Delphi study round three The author is not yet in a position to draw further conclusions as the final Delphi study round is aiming to draw together the results from the first and second rounds, as well as asking further research questions. In acknowledging that the participant rate was 16%, the study cannot claim to know how other Trusts are utilising the SSC. Given the timing and context in which the Delphi study was carried out, it is appreciated that other priorities could have had an impact on trusts' ability and willingness to participate. Nevertheless, it was perhaps surprising to discover over a decade after the initial launch, that there is a lack of direction/leadership and that lack of multidisciplinary team engagement is still an issue. LocSSIPs 2 are due to launch early in 2023 and in order for this to be successful, training must take place, but most importantly NHS England need to hold trusts to account for not introducing them. A long-standing debate around whether surgical (non-airway) fires should be classified as a Never Event was asked to the theatre safety experts, with an overwhelming response agreeing that this type of event should be added to the reportable Never Event list. The study has also raised questions that will be answered in the third Delphi round.

This paper addresses information raised as part of a Delphi study of NHS hospital operating theatres in England. The aim of the first Delphi study round was to establish how the World Health Organisation’s Surgical Safety Checklist (SSC) is currently being used in the peri-operative setting as part of a strategy to reduce surgical ‘never events’. It used a combination of closed and open-ended questions that solicited specific information about current practice and research literature, that generated ideas and allowed participants freedom in their responses. The study asked theatre managers, matrons and clinical educators that work in operating theatres and deliver the surgical safety checklist daily, and who are therefore considered to be theatre safety experts. Participants were from the seven regions identified by NHS England. The study revealed that the majority of trusts don’t receive formal training on how to deliver the SSC, checklist champions are not always identified, feedback following a ‘never event’ is not usually given and that the debrief is the most common step missed. While the intention of the study was not to establish whether the lack of training, cyclical learning and missing steps has led to the increased presence of never events, it has facilitated a broader engagement in the literature, as well highlighting some possible reasons why compliance has not yet been universally achieved. Furthermore, the Delphi study is intended to be an exploratory approach that will inform a more in-depth doctoral research study aimed at improving patient safety in the operating theatre and informing policy making and quality improvement.