How to learn from the never event

How to learn from the never event

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“I’m in charge, don’t you trust me”! “Checklists? Bah, a waste of time”.

Attitudes like this can lead to ‘never events’ in the operating theatre, those serious adverse events that should never happen because adequate guidance is already available. But, Suzanne Shale, Chair of the Surgical Never Events Taskforce is on record as saying “surgical never events almost always occur as a result of systems that are not safe enough, combining with behaviours that are not safe enough” [1]

According to a recent meta-analysis of ‘never events’ in the US between 2004 and 2014, the occurrence of wrong-site surgery and retained surgical items is between 1 event per 100 000 and 1 event per 10 000 procedures [2]. But even this frequency is not acceptable for events that are entirely preventable. The consequences can be serious, and not only for the patient. Dawn Stott, Chief Executive of the Association for Perioperative Practice (AfPP) told Healthcare Arena that after the initial departmental review, the fallout from a never event is managed by the NHSLA (NHS Litigation Authority) who deal with insurance and any potential litigation. The cost of just investigating the event can start at £10,000, and compensation can run into millions.

But how can never events be prevented and what is an NHS Trust to do if it is worried about its never events record?

This was precisely the situation faced recently by a forward-thinking NHS Trust in the Midlands that approached the AfPP for advice. The AfPP was well placed to help the Trust with this challenge. As a membership organisation and registered charity, AfPP works to enhance skills and knowledge within operating departments, associated areas and sterile services departments and has developed important standards and recommendations.

The AfPP began by working with the Trust to conduct an initial audit and followed this with a document review and focus group. Even at this early stage, Dawn Stott could see how interactions between team members and lack of attention to checklists such as the WHO Surgical Safety Checklist [3] and the AfPP’s own “Standards and recommendations for safe perioperative practice” contributed to the problem. (One of Dawn Stott’s ambitions is to see a copy of the “Standards” in every operating theatre in the UK [4]!)

The preliminary audit and focus group work led to the recommendation for a whole-team approach and allowed AfPP to plan the content for a week’s training covering: accountability and liability, the safety checklist, communication (dealing with conflict or aggressive behaviour), clinical risk and the effectiveness of the teams.

The Chief Executive of the Trust agreed to the necessary theatre downtime enabling the training to focus on the whole team for a week, with classroom sessions supported by simulation and scenario-based workshops. The training took the participants on a journey that eventually won both hearts and minds, with significant progress from “I am here under duress” to “OK, I can see that, maybe I will try it”!

Dawn Stott explained that once the week’s training was complete the results were quite remarkable. Feedback from the NHS Trust noted that “one theatre team has commented on a positive improvement in another clinician’s behaviour and attitude”. And the Care Quality Commission (CQC) made an unannounced visit following the delivery of the training and announced “It felt like a different organisation, particularly in the theatres”.

She argues that safe operating theatre practices are all dependent on recognition of accountability and liability: “we are all accountable for our actions, and a team is only as effective as the people in it. It’s not always the skill you bring, it’s how you perform within the team that makes it effective. You can be the most skilled practitioner and you can be fully up to date but if you have a poor attitude and you’re not able to engage with other members of the team then you might as well not be there.”

AfPP’s vision of the future

The AfPP began life as the National Association of Theatre Nurses (NATN) in 1964. With a membership currently approaching 6500, the AfPP provides education and support to theatre nurses, operating department practitioners and all those working in and around operating departments. The AfPP’s primary aim is to enhance the quality of care in the NHS and the independent sector throughout the UK.

The AfPP isn’t just concerned with training and professional development of members, it is also about helping members to have an impact on their own environment. As Dawn Stott explains,one of the roles of AfPP’s is to “empower people to speak up and speak out if they think something is wrong”.

Dawn Stott and her team have a clear strategy for the development of the AfPP in the next five years. Increasing the membership and encouraging the participation of younger members will be crucial element along with the continuing development and promotion of the AfPP’s image and reputation and the ongoing provision of advice and training to the membership.

Strengthening the financial position is another of Dawn’s responsibilities. In times past the AfPP used to fund many of its activities through congress and exhibition activities but as times change this is no longer a viable option and new strategies have emerged such as the consultancy initiative for advice, audit and training and the structured Training Academy, which has been designed to provide the highest quality bespoke clinical education to suit the needs of healthcare providers, in both the NHS and private sector.

To find out more about AfPP visit: http://www.afpp.org.uk/home

 

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

References

  1. NHS England » New recommendations to further improve surgical safety [Internet]. [cited 2015 Sep 13]. Available from: http://www.england.nhs.uk/2014/02/27/surgical-safety/
  2. Hempel S, Maggard-Gibbons M, Nguyen DK, Dawes AJ, Miake-Lye I, Beroes JM, et al. Wrong-Site Surgery, Retained Surgical Items, and Surgical Fires : A Systematic Review of Surgical Never Events. JAMA Surg. 2015 Aug 1;150(8):796–805.
  3. WHO | Patient safety checklists [Internet]. WHO. [cited 2015 Sep 13]. Available from: http://www.who.int/patientsafety/implementation/checklists/en/
  4. Association for Perioperative Practice (Great Britain). Standards and recommendations for safe perioperative practice. Harrogate: Association for Perioperative Practice (AfPP); 2011.

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