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Found 76 results
  1. News Article
    A record number of "foreign objects" have been left inside patients' bodies after surgery, new data reveals. Incidents analysed by the PA news agency showed it happened a total of 291 times in 2021/22. Swabs and gauzes used during surgery or a procedure are one of the most common items left inside a patient, but surgical tools such as scalpels and drill bits have been found in some rare cases. A woman from east London described how she "lost hope" after part of a surgical blade was left inside her following an operation to remove her ovaries in 2016. The 49-year-old, who spoke to PA on condition of anonymity, said: "When I woke up, I felt something in my belly. "The knife they used to cut me broke, and they left a part in my belly." She added: "I was weak, I lost so much blood, I was in pain, all I could do was cry." The object was left inside her for five days, leading to an additional two-week hospital stay. Commenting on the analysis, Rachel Power, chief executive of the Patients Association, said: "Never events are called that because they are serious incidents that are entirely preventable because the hospital or clinic has systems in place to prevent them happening. "When they occur, the serious physical and psychological effects they cause can stay with a patient for the rest of their lives, and that should never happen to anyone who seeks treatment from the NHS. "While we fully appreciate the crisis facing the NHS, never events simply should not occur if the preventative measures are implemented." Read full story Source: Sky News, 4 January 2022
  2. Content Article
    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.
  3. Content Article
    Postoperative patients were sampled from surgical wards at two large London teaching hospitals. Patients were shown two professionally produced videos, one demonstrating use of the WHO surgical safety checklist, and one demonstrating the equivalent periods of their operation before its introduction. Patients’ views of the checklist, its use in practice, and their involvement in safety improvement more generally were captured using a bespoke 19-item questionnaire. 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.
  4. Content Article
    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. 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.
  5. News Article
    Hardeep Singh, an informatics leader, patient safety advocate and innovator, and friend of the Jewish Healthcare Foundation (JHF), has been awarded the Individual Achievement Award in the 20th John M. Eisenberg Patient Safety and Quality Awards for demonstrating exceptional leadership and scholarship in patient safety and healthcare quality through his substantive lifetime body of work. The Joint Commission and National Quality Forum present Eisenberg Awards annually to recognise major achievements to improve patient safety and healthcare quality. Dr Singh, chief of the Health Policy, Quality & Informatics Program in the Center for Innovations in Quality, Effectiveness and Safety at Michael E. DeBakey VA Medical Center and professor at Baylor College of Medicine, was recognised for his pioneering career in diagnostic and health IT safety and his commitment to translating his research into pragmatic tools, strategies, and innovations for improving patient safety. His commitment to improving patient safety began while pursuing his Master of Public Health at the Medical College of Wisconsin in 2002 when he first learned the field of patient safety existed. That commitment was galvanised early in his medical career, as he found himself treating patients who had been misdiagnosed, received unsafe care, or experienced poor outcomes. The breadth and depth of Dr Singh's research work is remarkable, but what is most notable is the extent to which he has succeeded in translating it into pragmatic strategies and innovations for improving patient safety. Dr. Singh emphasised that while the Eisenberg Award recognizes an individual for their achievements, his work in patient safety has been successful because of its multi-disciplinary and collaborative approach with psychologists, human factors engineers, social scientists, informaticians, patients, and more. That work has led to the development of several tools to improve patient safety, including The Safer Dx Checklist, which helps organizations perform proactive self-assessment on where they stand in terms of diagnostic safety. "As an immigrant and an international medical graduate, I have had a lifelong dream to make an impact on health care. I saw every scientific project as an opportunity to change health care. So, I made a personal commitment that my research must use a pragmatic, real-world improvement lens and challenge the status quo in quality and safety," Dr. Singh said. Read full story Source: Jewish Healthcare Foundation News, 31 August 2022
  6. Content Article
    How to use the checklist Identify a senior leader (e.g., chief quality officer, chief patient safety officer, chief medical officer, or other clinician with oversight of quality) in the organisation who can serve as the champion for learning and exploration of diagnostic excellence. Establish a multidisciplinary team of individuals from various clinical and non-clinical disciplines, including quality and safety, patient representatives, medical educators, and trainees. This team should meet regularly to review and analyse the current state of diagnostic safety and work toward implementation of all 10 checklist items. Complete the checklist as a team or independently. If independent review is preferred, team members should discuss responses and come to consensus on next steps. Develop an action plan that includes clear next steps, metrics of progress, and roles and responsibilities to oversee implementation. The plan needs to be supported by the senior leader champion. Identify regular checkpoints for follow up that include annual review of the checklist and periodic monitoring and revisions to the action plan.
  7. Content Article
    The article is found on pages 10-12 of the digital edition of the journal.
  8. Content Article
    The anaesthetist has a primary responsibility to understand the function of the anaesthetic equipment and check it before use. Anaesthetists should not use equipment unless they have been trained in its use and are competent to do so. A self-inflating bag should be immediately available in any location where anaesthesia is given. A two-bag test should be performed after the breathing system, vaporisers and ventilator have been individually checked. A record should be kept with the anaesthetic machine that these checks have been carried out. The ‘first user’ check, after servicing, is especially important and should be recorded.
  9. Content Article
    Recently Dr Peter Brennan tweeted a video of a plane landing at Heathrow airport during Storm Dennis. I looked at this with emotion, and with hundreds of in-flight safety information, human factors, communication and interpersonal skills running through my head. I thought of the pilot and his crew, the cabin crew attendants and the passengers, and how scared and worried they would have felt. On a flight, the attendants will take us through the safety procedures before take off. We are all guilty, I am sure, of partly listening because it is routine and we have heard it all before. Then suddenly we are in the midst of a violent storm and we need to utilise that information! We ardently listen to the attendants instructions and pray for the captain to land the plane safely, which he does with great skill! I now want to link this scenario to the care of our patients in the operating theatre. They are also on a journey to a destination of a safe recovery and they depend on the consultants and the team to get them there safely. Despite being routine, we need to do all the safety checks for each patient and follow the WHO Surgical Safety Checklist as it is written: ask all the questions, involve all members of the surgical team, even do the fire risk assessment score if it is implemented in your theatre. The pilot of that flight during Storm Dennis certainly did not think he was on a routine flight. He had a huge responsibility for the lives of his crew and many passengers! We can only operate on one patient at a time. Always remember, even though the operation may be routine for us, it may be the first time for the patient – so let's make it a safe journey for each patient. Do it right all the time!
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