Search the hub

In the study, Yonash and Taylor identified instances of WSS events (not including near misses) that occurred during 2015–2019 and were reported to PA-PSRS. During the five-year period, they found that 178 healthcare facilities reported a total of 368 WSS events, which was an average of 1.42 WSS events per week in Pennsylvania.They also found that 76% (278 of 368) of the WSS events contributed to or resulted in temporary harm or permanent harm to the patient. Overall, the study shows that the frequency of WSS varied according to a range of variables, including error type (e.g., wrong side, wrong site, wrong procedure, wrong patient); year; facility type; hospital bed size; hospital procedure location; procedure; body region; body part; and clinician specialty. Our findings are aligned with some of the previous research on WSS; however, the current study also addresses many gaps in the literature. We encourage readers to use the visuals in the manuscript and appendices to gain new insight into the relation among the variables associated with WSS. Ultimately, the findings reported in the current study help to convey a more complete account of the variables associated with WSS, which can be used to assist staff in making informed decisions about allocating resources to mitigate risk.

I believe all clinicians should read this latest report. There is so much to be learned and so many changes in clinical practice that can be made right away. Since 2018, I have been teaching using Oliver's tragic story to promote reflection on best practice in prescribing and in implementing the Mental Capacity Act. I could write a lot here; however, I believe this is a report all clinicians, and especially all prescribers, need to read in full. A summary of how I see this (or indeed how any individual sees it) it will not be adequate.

Developing the FRAS In January 2017, I read a tragic story in Outpatient Surgery involving an elderly patient in the US who suffered multiple burns following the use of chlorohexidine bottled alcoholic prep. I'd also read that in the US there are over 600 surgical fires every year. As the Practice Development Lead for my theatre department at the time, I decided to design a Fire Risk Assessment Score (FRAS). I discussed the FRAS with my manager and my suggestion to add the FRAS to the 'Time Out' of our WHO Surgical Safety Checklist. To further develop my ideas, I attended one of the Association for Perioperative Practice (AFPP) study days. All the delegates were asked to discuss and write a plan to make an immediate change in practice on return to their theatre department. I planned the FRAS. My manager who had originally agreed to my idea in January left in March, but I persevered with the idea and in July 2017 I made copies of the FRAS, discussed the score with senior staff, laminated the copies and placed one in each theatre. It was used as part of the WHO Surgical Safety Checklist Time Out. One month later I moved on and started bank shifts as a scrub practitioner in theatres. Fast forward 3 years Imagine my delight on a bank shift in August 2020 to see the FRAS as part of the patient profile on the hospital computer system – which meant it was in all six hospitals! So have fires decreased in theatres? Research shows that fires are still occurring in some UK theatres, and around the world, where a score is not part of the 'Time Out'; where bottled alcoholic prep is still used and not allowed to dry for 3 minutes before draping; and where lighted cables are sometimes allowed to rest on paper drapes. All perioperative staff need to have an awareness of surgical fires – where each flammable item used for the procedure is counted as 1 risk, and the score highlighted to the team and also documented before the start of the surgery. In doing this we can be reassured that we have taken all the necessary fire safety precautions for patients in our care, for the perioperative surgical team and also the preservation and the reputation of the hospital. Further reading The FRAS tool Kathy implemented Yardley IE, Donaldson LJ. Surgical fires, a clear and present danger. The Surgeon 2010; 8(2):87-92. Alani H et al. Prevention of surgical fires in facial plastic surgery. Australas J Plast Surg 2019; 28:40-9. Vogel L. Surgical fires: nightmarish “never events” persist. CMAJ 2018;190(4): E120. Cowles Jr CE, Culp Jr WC. Prevention of and response to surgical fires. BJA 2019; 8:261-266.

Key points Communication between members of the surgical team is an integral component of the prevention of surgical fires. Open delivery of 100% oxygen should be avoided if at all possible for surgery above the xiphoid process. Surgeons usually control the ignition sources, such as electrosurgical units and lasers. Operating theatre nurses or practitioners usually control the fuel sources, such as alcohol-based preparations and surgical drapes. The use of an ignition source in close proximity of an oxidiser-enriched environment creates a high risk for surgical fires.

In the late eighties, I attended a presentation on the future of the UK Medtech sector presented on behalf of the government by KPMG. The main message being the government’s desire for the industry to focus on research and development whilst transferring manufacturing to China! What relevance does this have to patient safety? Fast forward some twenty years and I am presenting the case for adoption of one of our most successful unique patented patient safety products (successful global use at this point around the 5 million patient level) to one of the largest NHS trusts. The difficulties faced by industry The trust we presented to operates a clear policy that industry should not even provide literature on products to any clinician unless procurement permission is given. We complied with this policy and were invited in to present after an anaesthetist had highlighted that the trust had experienced patient injury from the current standard practice of using rolls of tape to secure patients' eyes during anaesthesia to protect from hazards and prevent the eyes from drying out causing potentially serious harm. Our product literature carries an endorsement from the Association of Perioperative Practice who clearly state that the practice of using tape to address these issues is “not recommended and that Eyepads fit for purpose should be used”. The meeting is attended by a man from procurement and a Sister from the trust with many years of experience in her role. I present the product case and pass samples to the Sister. Within a minute of handling the product she dismisses the product as “expensive nonsense”! The man from procurement proclaims the session over and we part company. The anaesthetist that initiated the meeting was not present and was not allowed to take her desire to try our solution any further. This story is reflective of not only our experience but typical of the path we and other Medtech companies encounter in attempting to introduce new innovative patented solutions to the NHS UK companies. The drive towards ever cheaper manufacturing adoption by the NHS is led by NHS supply chain, dominating the tendering market for products with multiple manufacturing sources. The NHS is now globally recognised as a procurement-driven market, focussed on reducing costs through purchasing and negotiating lower pricing. An organisation that issues “zero inflation pricing increase” policies. This can be very effective and is certainly a major driving factor in the success of the multitude of Chinese manufacturing companies supplying the NHS. A market that has produced a multitude of failed schemes for the adoption of new technologies in favour of sourcing ever cheaper, often poor quality products. But we did not jump on that bandwagon and instead chose to continue working with the best patented technological solutions emerging. We recently had the pleasure of working with Helen Hughes and Patient Safety Learning on a webinar presenting one such product. We introduced this product over a year ago and immediately engaged with the latest NHS Accelerated Access Collaborative innovation adoption scheme. In the webinar I described how this and all of our other efforts had failed to make any serious impact other than producing great results with a small band of community health nurses. Then COVID-19 strikes and almost overnight procurement is bypassed. There is a priority in addressing shortages of products perceived as vital in maintaining care levels in the impending increased demand due to COVID-19. This leads to the successful sale of several hundred of our units. However, when the government moves to address the issue through large scale purchase of the product, our solution is dismissed and offered no part of the contracts awarded in a process that was uncannily like the experience described above. A culture of cost cutting and fear Management of the NHS is an enormous undertaking. However, I would suggest that many years of focus on cost cutting has delivered a culture of fear and apathy toward the adoption of the amazing new technologies that can transform care. The plethora of schemes for innovation adoption that we have engaged with over the years have failed, often at the outset, simply due to inadequate funding and planning. During this period industry has also had to bear the substantial increased costs of product and staff regulatory changes. When I engage with some of these schemes, I cannot understand why there are so many companies in the mix pitching products and services that have nothing to do with healthcare, but offer instead procurement or management “more efficient management” tools! Some trusts appear to be more concerned with this aspect than the actual delivery of healthcare. One trust insists that we supply our products through a third-party purchase company because the product they buy is not listed on NHS supply chain. They have now ceased to order after the third-party supplier entered administration, owing us several thousand pounds! In November we will launch a new patented product with patient safety benefits, invented by two operating department practitioners (OPDs) in Liverpool. We will manufacture the product in the UK and manage global marketing from the UK. However, we are currently focused on marketing the product overseas; engaging with NHS procurement is not a priority. I know other companies have that same view. It’s recognised that efficient procurement is an important element of NHS management, largely developed from the political direction in the Eighties on cheaper globalised manufacturing policies. Unfortunately, whilst to some degree it has been very successful in cutting costs, patient and staff safety has on occasion been compromised. There is now a culture of cost cutting with procurement completely focused on this. Call for action NHS adoption of new beneficial technologies is woefully inadequate and remains largely under the control of procurement services often disinterested in it and unqualified to manage it. For patient and staff safety to benefit, I would like to see: Simplified fast-tracked product assessment procedures managed by appropriately qualified staff. The removal of products and services designed for healthcare management from the assessment of products directly involved in improving healthcare outcomes. Our current structures are simply not fit for this purpose. Stewart Munro is Managing Director of Pentland Medical Ltd.

This easy reference guide has been produced because: Some aspects of COVID-19 presentation and treatment present special challenges for safely confirming nasogastric tube position. The dense ground-glass x-ray images can make x-ray interpretation more difficult, and the increasing use of proning manoeuvres in conscious patients increases the risk of regurgitation of gastric contents into the oesophagus and aspiration into the lungs which will render pH checks less reliable. This aide-memoire is not designed to replace existing, established, NHSI compliant practice of NG confirmation. If a critical care provider is in the fortunate situation of having nursing and medical staff who have all completed local competency-based training in nasogastric tube placement confirmation aligned to local policy, they would be able to continue more complex local policies. Such policies might include specific advice indicating which critical care patients could have pH checks for initial placement confirmation, and which require x-tray confirmation, and how second-line checks should be used if first-line checks are inconclusive. However, staff returning to practice, or redeployed to critical care environments, including in Nightingale hospitals, will be helped by reminders of established safety steps in a form that can be used for all critical care patients, rather than requiring different processes for different patients. This is version 2 of the aide memoire, which includes additional advice on situations where providers can continue to safely use more complex local polices. Other changes were minor refinements of language and use of capital letters to emphasise application to checks before first use.

We have all heard of the terrible stories of nurses going to the coroner’s court. These stories have been fed to us by our seniors, our mentors, our lecturers since we were students. "If you don’t document properly, you will end up in the coroner’s court, you might even get struck off!" These stories strike the fear of god into you. No one wants to go to coroner’s court, no one wants to be criticised for the work they have spent years training to do. No one wants to be publicly humiliated. This is my story of what happened when I attended a coroner's hearing on a patient who was in my care. I was a band 6 at the time. It was a usual day on the medical ward. Busy. I had a bay of six patients. Three of them were fit for discharge, but no community placement for them to go to, two medical patients and one who was a surgical patient. The surgical patient was under the medics and the surgeons. He came with abdominal pain; he was waiting for a surgical review. Many patients are under numerous teams on the medical ward. One of my roles is to ensure that they get seen by each team every day to ensure a plan for treatment. Today was no different. The patient was seen by the medical team who said "await surgeons". I chase up the surgeons, but they are in theatre. From experience I know that they will be out of theatre by late afternoon – so hopefully I can catch them then. In the meantime, the surgical patient becomes unwell. His blood pressure drops, his NEWS of 5 from 0. He is tachycardic. I call the medics who attend – they want me to call the surgeons… no answer. Intensive care team arrive – to this day I’m not sure how they knew to come, perhaps one of the medics called them? The intensive care doctors I hear raging down the phone at a poor surgeon who is in theatre. The surgeon comes to the ward and soon realises the gravity of the situation. There are discussion that are being had away from the bedside – I’m not sure what was being said or plans that were being made. I was not part of the process. I’m busy doing observations every 5 minutes as requested, plus trying to look after my other five patients. All of a sudden we are going to theatre. I’m still unsure what’s going on. What’s he going there for? The patient looks really scared. I bet I look scared too! I help wheel him down to the operating theatre. As soon as we arrive in the anaesthetic room he has a cardiac arrest. We try and resuscitate him to no avail. I went back to the ward; bewildered, sweating from doing chest compressions, confused and with tears in my eyes. I have a quick cup of tea and I’m back out on the ward again. Three months later my manager asks to see me in the office. ‘What have I done wrong?’ When anyone asks for you to come to the office, its usually bad. They ask if remember the surgical patient who arrested a few weeks back. Of course, I do. I had been thinking about it ever since. I had been worrying about it. I felt it was my fault. They tell me that the case is going to the coroner's court and I was to be called as a witness. I cry. That’s me done then. I’m going to be struck off. I’m going to be found out that I am a rubbish nurse. My manager was amazing. They had experience in these hearings. They explained the whole process. From what would happen from now until the end of the hearing. That afternoon I was contacted by the Trust investigation team. They were lovely too. They asked me exactly what happened and help me write a statement. They put me at ease. It was made clear that what happened was not my fault and that they want to find out what happened to prevent it happening again. The next week or so I had contact with the Trust legal team. I had never spoken to a legal team before in my life. I did feel as if I was a criminal at first. The legal team were also brilliant. They spoke through the actual process; who was in the room, the layout of the room, what questions I might be asked, what the outcomes often are. They gave me advice on how to answer questions; answer what you know as fact, not opinion. If you don’t know, say you don’t know. Be honest. I had two further meetings with the legal team and the investigating team. This was to check I was ok, to make sure I was supported. For what could be an extremely stressful period of my career, was made so much easier by people taking the time out just to check I was ok. I carried on working throughout this period and working with confidence. The hearing came. I knew what to expect. I knew the layout of the room. I knew the patient’s relatives were in the front row, I knew I had to swear an oath, I knew I had support from my Trust. I was able to speak freely – even the bad bits; no covering up or making excuses for others. I was asked what happened that day. I was honest. I didn’t know what was going on. I didn’t know what was wrong with my patient. I was not used to caring for surgical patients. Admitting that I ‘didn’t know’ was awful. I should know, shouldn’t I? When I was saying this, I could feel the eyes of the patient's widow bore into me. I had let my patient down and I had failed. The coroner asked me many questions related to escalation of care to seniors, the policy, my adherence to the NEWS policy – to which I had followed. My part was over in a flash. The next was the surgeon, who got most of the grilling. Why was he not there, where was his documentation, why did he not come when asked repeatedly? It wasn’t his fault either. He was in theatre with another patient. He can’t be in two places at once. I felt really sorry for him. I hope he got the same support I did. The outcome of the hearing was to issue a regulation 28. This ensures that a report is sent to the government by the Trust as the coroner believes that action needs to be taken can to prevent future preventable deaths. So, what happened then? I went back to work and carried on as usual. The ward where I worked no longer takes surgical patients. They made a new unit called the ‘surgical assessment unit’ where surgical nurses care for this cohort of patients. I wanted to share this – yes, there are many issues surrounding this, but the point I wanted to get across is that the investigation team, my manager and the legal team supported me through this difficult time. I am not sure if other Trusts have this level of support for staff attending coroners court.

Five tips: People aren't machines Push the button Differeing shapes and sizes Stamina and repetition Look around

This is a template that can be used by health professionals carrying out medicines reconciliation.