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The Association for Perioperative Practice (AfPP) is calling for action to be taken after a recent report suggests little progress has been made to prevent errors within the perioperative environment. The patient safety charity made the call following the release of NHS Improvement’s latest Never Event report; Provisional publication of Never Events reported as occurring between 1 April and 31 December 2019, which revealed an alarming 81% (284) of the never events recorded happened while a patient was on the operating table. Lindsay Keeley, patient safety and quality lead at AfPP said: “The survey highlighted that there’s a need to take action now if we are to support the healthcare profession in reducing the occurrence of never events. It has become clear that receptive team culture, a strong leadership team and better support for staff is what will help to reduce the risk of a never event occurring. It’s vital that those in leadership positions begin to understand the contributory factors in the recurrence of never events and the challenges faced by staff." She went on to highlight some of the recent initiative taking place: “What is promising is that there are practitioners who are developing new, practical and simple solutions every day that can support other team members and can be used within theatres across the country." "One example is Rob Tomlinson’s introduction of the 10,000 Feet initiative – a safety initiative designed to cut through noise and distraction within the theatre environment, particularly at critical points of the patient’s journey. If correctly implemented, initiatives like this can cut through the hierarchies that stop people feeling unable to speak up when they see something that shouldn’t be happening, thus reducing the occurrence of never events" “We of course need to be mindful that there will always be challenges within perioperative practice in the form of interruptions and distractions, but the key is how as practitioners we engage with this to recognise and reduce never events.” Read full story Source: Clinical Services Journal, 25 February 2020

One of the country’s smallest trusts recorded 277 serious incidents over a two-year period, HSJ can reveal. Delays in treatment, missed diagnoses, adverse media coverage and “suboptimal” care were among the hundreds of serious incidents reported at the struggling Isle of Wight Trust from the start of 2018 and up to November 2019. There were also two never events in 2019 — a “wrong site” surgery and an incident in which a patient was mistakenly connected to an air flow meter, rather than an oxygen supply. The trust said the level of incidents did not neccessarily reflect poor care, and did not mean patients had come to harm. The trust was placed in special measures in April 2017 after it was rated “inadequate” by the Care Quality Commission due to “significant” concerns over patient safety. It was upgraded to “requires improvement” in September 2019, but remains in special measures. Read full story (paywalled) Source: HSJ, 22 January 2020

Hi The new Patient Safety Incident Response Framework is due for publication this month for early adopters and as 'introductory guidance' for everyone else: https://improvement.nhs.uk/resources/about-new-patient-safety-incident-response-framework/ I wondered if there is anyone who is involved in an organisation that is an early adopter who can share what has happened so far and also would be willing to share any local learning as the new framework is implemented? Also, more generally wondered if anyone has any initial comments on the proposals which were mentioned in the NHS patient safety strategy and any things in particular which they think will bring benefit or could represent significant challenges or issues?

A young woman was left with a retained foreign object, after surgery in an India hospital. A checklist could have avoided her death. The response from the health officials was: “We have issued a show-cause notice to the staff seeking an explanation. We will initiate departmental action based on their replies and finding of our inquiry.” In the fields of healthcare quality and patient safety, such punitive measures of “naming and shaming” have not worked. T.S. Ravikumar, President, AIIMS Mangalagiri, Andhra Pradesh, moved back to India eight years ago with the key motive to improve accountability and safety in healthcare delivery. He believes that we have a long way to go in reducing “preventable harm” in hospitals and the health system in general. "We need to move away from fixing blame, to creating a 'blame-free culture' in healthcare, yet, with accountability. This requires both systems design for safe care and human factors engineering for slips and violations". "Providing safe care without harm is a 'team sport', and we need to work as teams and not in silos, with mutual respect and ability to speak up where we observe any deviation or non-compliance with rules, says Ravikumar. Basic quality tools and root-cause analysis for adverse events must become routine. Weekly mortality/morbidity conferences are routine in many countries, but not a routine learning tool in India. He proposes acceleration of the recent initiative of the DGHS of the Government of India to implement a National Patient Safety Framework, and set up an analytical “never events” or sentinel events reporting structure. Read full story Source: The Hindu, 12 January 2020