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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.

This course is suitable for anybody who deals with complaints as part of their job role, or anybody who may have to handle a complaint. This includes dedicated complaints teams & customer support teams and managers. The programme includes a section on handling complaints regarding Covid-19 - understanding the standards of care by which the NHS should be judged in a pandemic. A highly interactive and effective workshop to improve confidence and consistency in handling complaints. A simple model to facilitate effective responses will be shared and delegates will have the opportunity to practise the use of our unique AERO approach. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/complaints-resolution-and-mediation or email kerry@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for discount code.

Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. It can be used to assess why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. This virtual masterclass, facilitated by Mr Perbinder Grewal, General Vascular Surgeon, will guide you in how to use Human Factors in your workplace. For full programme content, speaker line-up and to book visit www.healthcareconferencesuk.co.uk/conferences-masterclasses/human-factors-workplace hub members receive a 20% discount. Please email info@pslhub.org for discount code

The New Existence Webinar Series will take an in-depth look at The New Existence framework from The Beryl Institute. Helping to link core ideas and apply practices, each session in the series will focus on a key aim and corresponding actions of The New Existence. This webinar series will help to explore how lead together into the future of healthcare. The full webinar series is listed below. Webinars are scheduled from 2:00-3:00pm ET/1:00-2:00pm CT. Participants are not required to attend each webinar in the series. Click on a title below to register for the individual webinars in the series. Care teams Redefine and advance the integrated nature of and critical role patients and their circle of support play on care teams. January 28: Redefine the care team February 25: Invite and activate partnership March 25: Commit to care team well-being Governance & leadership Reimagine, redefine and reshape the essential role of leadership in driving systematic change. April 22: Create transparency across the healthcare ecosystem May 27: Restore and nurture confidence June 24: Transform healthcare in collaboration with diverse voices Models of care & operations Co-design systems, processes and behaviors to deliver the best human experience. July 22: Co-design intentional, innovative and collaborative systems August 26: Innovate processes of care to transform behavior Policy & systemic issues Advocate for equitable institutional, governmental and payor policies, incentives and funding to drive positive change. September 23: Hardwire human partnership in the healthcare ecosystem October 28: Research, measure and dismantle the structures and systems that lead to disparities November 23: Modernise the surveys and democratise the data