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Content ArticleThis National Patient Safety Alert, issued by the NHS England National Patient Safety Team and endorsed by the Royal College of Obstetricians & Gynaecologists, Royal College of Midwives and Royal College of Anaesthetists, instructs all relevant NHS funded maternity care providers to cease pre-preparing oxytocin infusions at ward level in all clinical areas. All actions should be completed by 31 March 2025. Midwives need to complete several tasks immediately and simultaneously following birth to ensure the safety of both the mother and baby. To support this, postpartum oxytocin infusions have been prepared in advance of being required. If a pre-prepared oxytocin infusion is unintentionally given before the baby is born, for example if it is confused with standard fluids or the intrapartum and postpartum infusions are confused, the woman’s contractions will increase in frequency and strength. This can lower the baby’s oxygen levels and alter their heart rate, increasing the risk of placental abruption (where the placenta prematurely separates from the uterus and deprives the baby of oxygen). A review of the National Reporting and Learning Systems over a 5 year period identified 25 incidents. Actions required: Review and update local clinical procedures (or equivalent documents) to ensure: Oxytocin infusions for any indication are not pre-prepared at ward level in any clinical area (including delivery suites and theatres). Post-partum haemorrhage (PPH) kits/ trolleys are immediately available in all clinical areas/theatres where it may be required. Where a woman is identified to be at high risk of PPH: (a) the PPH kit/trolley should be brought into the labour/delivery room/theatre during the second stage of labour, (b) the postpartum oxytocin infusion should be prepared at the time of birth and not before, (c) a second midwife should be available to support the administration of the postpartum oxytocin infusion. Roles and responsibilities of staff groups in the labour setting, including theatres, are clearly defined in terms of prescribing, preparation, administration and disposal of oxytocin infusions. Including: intrapartum oxytocin infusions, postpartum oxytocin infusions and unused, pre-prepared oxytocin. infusions.
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Engagement with patient & public networks
Patient Safety Learning posted an event in Community Calendar
untilThe Centre for Perioperative Care (CPOC) progresses a number of innovative and exciting collaborations with its patient facing partners since its origin in 2019. This webinar is designed to bring together lay and patient representation from both its Board and Advisory Group partners, as well as patient organisations and charities. The aim is to understand better the needs of patient and public engagement from a perioperative perspective. The webinar will include presentations from speakers investigating the Psychological and Behavioural science backgrounds of patients’ needs and wants, as well as patientvoices@RCOA. There will be an opportunity to develop these ideas in breakout groups to produce a consensus statement which CPOC will use to further develop the patient facing perioperative strategy. Considering the increasing waiting times that patients are having to process, while seeing their conditions potentially deteriorate, this is an opportunity to bring like-minded voices together to benefit patient outcomes within the UK. Further information -
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National NatSSIPs Network
Patient Safety Learning posted an event in Community Calendar
untilNHS England is currently seeking views on whether the existing Never Events Framework remains an effective mechanism to drive patient safety improvement. Never Events are defined as patient safety incidents that are ‘wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers’. This webinar, hosted by the National NatSSIPs Network and supported by Patient Safety Learning, will feature a panel discussion on the Never Events framework and the proposals set out in this consultation. The National NatSSIPs Network is a group of healthcare professionals aiming to reduce the number of patient safety incidents related to invasive procedures. Speakers: Helen Hughes Dr Annie Hunningher Dr Sam Machen Claire Cox Guest Speaker Guest Speaker Register- Posted
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Theatres & Decontamination Conference
Patient Safety Learning posted an event in Community Calendar
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EventJoin us for a full day of education covering those topics that are the basis of our (or your) everyday practice. From risk management to infection control and patient care to practitioners wellbeing, leave the day informed, challenged and inspired. Book your tickets
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Operating Theatres Conference 2024
Sam posted an event in Community Calendar
NHS England have set out an ambitious three-year plan back in February 2022, aimed at tackling the surgical backlog that has reached a record high following the pandemic. With a major milestone on the horizon to reduce wait times over a year by March 2025, we take a look at the progress being made and how trusts around the country are collaborating in order to drive down waiting times. Join Salford Professional Development for their 9th annual conference where industry leading speakers from all corners of the healthcare sector will come together to dive into captivating discussions on the key issues operating theatres are currently facing, alongside how they are driving innovation and utilising technology to support their practices. Hear unravelling insights on how to enhance sustainability, boost surgery productivity, amplify effectiveness, and work together in order to drive down the surgical backlog, ensuring a person-centred approach. This isn't just theory – it's practical wisdom you can immediately apply to your own surgical team. Case study examples and our panel of experts will illustrate how teams have transformed their practice and brought innovative solutions into play such as the HVLC delivery, GIRFT, Robotics and Sustainability action plans, and how they are tackling challenges facing the trusts theatres and beyond. Register -
Content ArticleTheatres are a high risk area. This poster from the Association for Perioperative Practice and BD illustrates how to plan and practise to manage a surgical fire. Download a pdf of the poster from the attachment below.
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Content ArticleOn Monday 10 July 2023 the Centre for Perioperative Care (CPOC) and Patient Safety Learning jointly hosted a webinar on the new National Safety Standards for Invasive Procedures 2 (NatSSIPs 2). This article contains links to video recordings of this webinar. The first half of the webinar featured the following subjects and speakers: Introduction - Professor Iain Moppett, CPOC NatSSIPs 2 Lead. The CPOC Perspective - Professor Scarlett McNally, CPOC Deputy Director. The Patient Safety Learning Perspective - Helen Hughes, Chief Exuecutive of Patient Safety Learning. Photo review of why NatSSIPs matters and what is new in NatSIPPs 2 - Dr Annie Hunningher, CPOC NatSSIPs 2 Lead. The Patient Perspective - Susanna Stanford, NatSSIPs 2 Patient Lead. The second half of the webinar featured the following subjects and speakers: Our NatSSIPs 2 workshop and how to consider a NatSSIPs gap analysis - Joe Allen, Suffolk and North East Essex Integrated Care Trust. Team Training for NatSSIPs 2 - Philip Gamston, Perfusion Service Manager at Barts Health NHS Trust. Resources to support NatSSIPs 2 implementation - Dr Dr Annie Hunningher, CPOC NatSSIPs 2 Lead. Q&A - Professor Iain Moppett, CPOC NatSSIPs 2 Lead. Are you a healthcare professional interested in learning more about NatSSIPs? On the hub we host the National NatSSIPs Network, a voluntary group of healthcare professionals aiming to reduce the number of patient safety incidents related to invasive procedures. You can join by signing up to the hub today. When putting in your details, please tick ‘National NatSSIPs Network’ in the ‘Join a private group’ section’. If you are already a member of the hub, please email [email protected].
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Content ArticleDr Liz O’Riordan is a breast cancer surgeon who has battled against social, physical and mental challenges to practise at the top of her field. Under the Knife charts Liz’s incredible highs: performing like a couture dressmaker as she moulded and reshaped women’s breasts, while saving their lives; to the heart-breaking lows of telling ten women a day that they had cancer. But this memoir is more than just an eye-opening look at the realities of training to be a female surgeon in a man’s world. In addition to this high-powered, high-pressured role, Liz faced her own breast cancer diagnosis, severe depression and suicidal thoughts, in tandem with commonplace sexual harassment and bullying. And by revealing how she coped when her life crashed around her, she demonstrates there is always hope.
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Content ArticleIntrahospital transport is a common occurrence for many hospitalised patients. Critically ill children are an especially vulnerable population who experience preventable adverse events at least once a week, on average. Transporting these patients throughout the hospital introduces additional hazards and increases the risk of adverse events. The transport process can be decomposed into a series of steps, each incurring specific risk. These risks are numerous and few of these risks are specific to the transport process. There is a paucity of literature available on paediatric intrahospital transport and related adverse events. Elliot et al. recently reviewed the Wake Up Safe database, a paediatric anesthesia quality improvement initiative across member institutions to disseminate information on best practices, for paediatric perioperative adverse events associated with anaesthesia-directed transport. The authors present several examples of airway and respiratory events taken from the database and discuss the complexity of the transport process.
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PIT stop (prosthesis/implant timeout) checklist
Nigel Roberts posted an article in Surgery
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: -
Content ArticleTony Clarke suffered from a chronic inflammatory skin disease, hidradenitis suppurativa. In September 2020, Tony underwent surgery to remove infected tissue on one side of his body. When he entered the operating theatre, Tony’s surgical team first covered part of his body with an alcohol-based solution, to keep the area clean. Then, when the operation began, the surgeons began cutting off the infected tissue using a diathermy pen, a device that targets electrically-induced heat to stop wounds from bleeding. However, shortly into the surgery, disaster struck: heat from the surgical pen had ignited the alcohol on Tony’s body. “But because alcohol burns so hot, no fire was seen,” says Tony, recalling an explanation he later received from the hospital. “The surgeons were concentrating on the right side of my body. The left side was left burning for about 20 minutes.” For the next four months, Tony travelled back to the hospital every three days, to get his injuries checked and bandages changed. During that time, Tony describes himself as ‘totally disabled.’ In September this year, Tony, as a patient ambassador for prevention of surgical fires, spoke at a conference held in York by the Association for Perioperative Practice (AFPP). There, perioperative practitioners from across the country gathered to listen to Tony’s experience. “I was speaking to lots and lots of different professionals in the medical service and they'd never heard of it [being set on fire during surgery]. It was a rarity for them,” Tony says. Tony’s now working with different health agencies, with the aim of stopping preventable surgical burns entirely.
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Content ArticleThis paper from Roberts et al. examines the application of the Surgical Safety Checklist (SSC) within NHS hospital operating theatres England. The aim of the study, through a combination of open-ended questions, was to solicit specific information including views and opinions from operating theatre experts to establish from how the World Health Organisations (WHO) SSC is being applied, and therefore and why intraoperative ‘Never Events’ continue to occur more than a decade after the SSC was introduced. Participants were from the seven regions identified by NHS England. The intention of this paper is not to establish definitively whether the quantitatively identified themes; including a lack of training and engagement with human factors explains the increased presence of intraoperative ‘Never Events’. However, these themes, when subjected to methodological triangulation with the current literature, do appear consistent, and therefore provide an exploratory approach to inform research intended to improve safety in the operating theatre by informing policy and its application to safe practice ultimately towards quality improvements.
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Marsha Jadoonanan, nurse and Head of Patient Safety and Learning at HCA Healthcare UK (HCA UK), spoke to us about a recent opportunity to learn from patient safety incidents involving wrong site anaesthetic blocks. She describes the new learning approach she and her colleagues used, which focused on engaging staff working in a variety of roles to create a safe space to focus on identifying ‘work as done’. -
Content ArticleCommercial aviation practices, including the role of the pilot monitoring, the sterile flight deck rule, and computerised checklists, have direct applicability to anaesthesia care. Checklists are commonly used in the operating room, especially the World Health Organization surgical safety checklist. However, the use of aviation-style computerised checklists offers additional benefits. In this editorial, Jelacic et al. discuss how these commercial aviation practices may be applied in the operating room.
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Content ArticleWatch this World Patient Safety Day webinar with Nigel Roberts on enhancing patient safety and surgical outcomes with the surgical safety checklist.
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Surgical Voices podcasts
Patient Safety Learning posted an article in Surgery
A series of podcasts from Molnlycke UK, with host Steve Feast, discussing topics such as sustainability, patient safety and more. Episodes: Sustainability in the operating theatre - guest speakers Tod Brindle, Molnlycke Medical Director, and Toby Cobbledick, Molnlycke Sustainability Specialist. Preventing surgical site infections: pre-surgery - guest speaker Lindsay Keeley, Patient Safety and Quality Lead AfPP. Preventing surgical site infections: post-surgery - guest speaker Lindsay Keeley, Patient Safety and Quality Lead AfPP. Supporting patients in their recovery from surgery - guest speaker Helen Hughes - Chief Executive of Patient Safety Learning. -
Content ArticleStandard operating procedures (SOPs) should improve safety in the operating theatre, but controlled studies evaluating the effect of staff-led implementation are needed. Morgan et al. evaluated three team process measures (compliance with WHO surgical safety checklist, non-technical skills and technical performance) and three clinical outcome measures (length of hospital stay, complications and readmissions) before and after a 3-month staff-led development of SOPs. They found that SOPs when developed and introduced by frontline staff do not necessarily improve operative processes or outcomes. The inherent tension in improvement work between giving staff ownership of improvement and maintaining control of direction needs to be managed, to ensure staff are engaged but invest energy in appropriate change.
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Content ArticleAccording to the World Health Organization, humanity faces its greatest ever threat: the climate and ecological crisis. Healthcare services globally have a large carbon footprint, accounting for 4-5% of total carbon emissions. Surgery is particularly carbon intensive, with a typical single operation estimated to generate between 150-170kgCO2e, equivalent to driving 450 miles in an average petrol car. The UK and Ireland surgical colleges have recognised that it is imperative for us to act collectively and urgently to address this issue. The Royal College of Surgeons of Edinburgh have collated a compendium of peer-reviewed evidence, guidelines and policies that inform the interventions included in the Intercollegiate Green Theatre Checklist. This compendium should support members of the surgical team to introduce changes in their own operating departments. The recommendations apply the principles of sustainable quality improvement in healthcare, which aim to achieve the “triple bottom line” of environmental, social and economic impacts. How to use the checklist The checklist is divided into four sections, the first dedicated to anaesthetic care, and the subsequent three looking at preparation for surgery, intra-operative practice and post-operative measures. It is suggested the checklist is initially used at the daily brief at the start of an operating list, as an aide-memoire for the team of the modifications that could be applied there and then. Once these practices become embedded into practice, then the checklist may be used less frequently. At present, some theatres will lack the infrastructure required to enact all the suggested interventions and so the checklist can serve as a roadmap for discussion with management, or at departmental meetings, to guide required changes. Finally, if completed regularly, the checklist could also be used as a scorecard to monitor progress.
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Content ArticleTraditional approaches to patient safety and handoffs need redesigning to acknowledge the different constraints, goals, and requirements necessary for each individual patient. There is no “one size fits all” approach to patient safety, handoffs or a perfect checklist. Despite the inherit complexity present in healthcare systems, we tend to reduce our thinking about handoffs into simple solutions of checklists and cognitive aids. In studies of these tools, their association with patient outcomes is unclear with mixed results in large studies. Incorporating general resilience engineering principles of visibility, understanding, anticipation, and learning provides new opportunities for increased patient safety. This involves situating the handoff in the context of the system - understanding the process of summarising pre-handoff and of developing understanding post-handoff, tracing flows of information and patients, and considering the role of feedback and control loops in the system. Direct observations, analysis of multiple outcomes, focus on patient evolving specific exceptions, reducing the number of handoffs, taking time for two-way discussions, and user-centred design and redesign may promote acceptability and sustainability of a new view of handoffs for improved patient safety.
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Content ArticleMaria Koijck's goal for this film was to create a movement within the pharmaceutical industry considering the waste it produces. In this film you see Maria lay in the middle of an incredible amount of waste from just one surgery, her surgery. In August 2019 Maria was diagnosed with breast cancer. Surgeons had to remove her entire left breast. After a successful recovery, she went to to have a deep lap surgery where they gave her an entire new breast of her own bodily materials. During this process she discovered that 60% of the surgery materials used for this operation is disposable. For example: the stainless steal scissors that are flown in from Japan, are used for one cut before they end up in the bin. Maria asked the doctors to collect all of the surgery materials used for her operation, to get a clear idea of how much it really was. She was shocked to see six bags full of plastic waste.
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Content Article
The IPP (Innovation, People and Practice) magazine
Patient Safety Learning posted an article in Surgery
Published 10 times a year by the Association for Perioperative Practice, the IPP covers a variety of topics relevant for perioperative practitioners. Ranging from news and information, special focus pieces, industry interviews and profiles of company leaders in an easy-to-read format. -
News Article
Researchers study brain activity of surgeons for signs of cognitive overload
Patient Safety Learning posted a news article in News
It is a high-stakes scenario for any surgeon: a 65-year-old male patient with a high BMI and a heart condition is undergoing emergency surgery for a perforated appendix. An internal bleed has been detected, an anaesthetics monitor is malfunctioning and various bleepers are sounding – before an urgent call comes in about an ectopic pregnancy on another ward. This kind of drama routinely plays out in operating theatres, but in this case trainee surgeon Mary Goble is being put through her paces by a team of researchers at Imperial College London who are studying what goes on inside the brains of surgeons as they perform life-or-death procedures. Goble looks cool and collected as she laparoscopically excises the silicon appendix, while fending off a barrage of distractions. But her brain activity, monitored through a cap covered in optical probes, may tell a different story. The researchers, led by Daniel Leff, a senior researcher and consultant breast surgeon at Imperial College healthcare NHS Trust, are working to detect telltale signs of cognitive overload based on brain activity. In future, they say, this could help flag warning signs during surgery. “The operating theatre can be a very chaotic environment and, as a surgeon, you have to keep your head and stay calm when everyone is losing theirs,” said Leff. “As the cognitive load increases, it has major implications for patient safety. There’s no tool we can use to know that surgeon is coping with the cognitive demands of that environment. What happens when the surgeon is maxed out?” In the future, Leff envisages a system that could read out brain activity in real-time in the operating theatre and trigger an intervention if a surgeon is at risk of overload. Read full story Source: 2 March 2024 -
News ArticleTheatre staff at a major hospital “deliberately slowed down” elective activity to limit the number of operations that could be done each day, an NHS England review has been told. The culture in theatres at the William Harvey Hospital in Ashford, run by East Kent Hospitals University Foundation Trust, was a “significant issue” according to an education quality intervention review report into trauma and orthopaedic training at the hospital. The review, dated October and made public by NHSE in December 2023, was launched after concerns were raised by staff at the trust in the General Medical Council’s national training survey, published every July. Problems raised by junior doctors and their supervisors to the NHSE review included perceptions that juniors were made to feel uncomfortable by the trauma theatre team and that there was also “animosity” from the trauma theatre team towards surgeons. The review said trauma theatre staff were heard “bragging” about their behaviour towards surgeons and that they resisted the number of cases scheduled on a list, claiming it was “unrealistic". Read full story (paywalled) Source: HSJ, 19 January 2024
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