Surgery (WHO, 2008).11 The term ‘Never Event’ was first
introduced by Ken Kizer, in 2001, in reference to shocking medical errors that should never have occurred (Lembitz and Clarke, 2009).12
Most
accidents are rarely the result of isolated errors committed by individuals but, instead, are the result of multiple, smaller errors occurring in an environment with system flaws (‘Systems Approach’, 2012, cited in Collins et al, 2014).13 According to the ‘Swiss cheese’ metaphor, the slices of cheese are layered, and each layer is a defence (e.g. the SSC) against the holes in the cheese, which represent a problem or error in the system (e.g. active failures). The more layers of cheese, the less likely it is that the holes will line up for an error to occur (Reason, 2000, cited in Collins et al, 2014).13
Surgery is one example
of where clinicians are faced with high levels of uncertainty in their daily work, which may impact on the quality and safety of care patients receive (Tucker and Spears, 2006).14
Human
error involves a deviation in procedure, policy or behaviour, but slips and lapses occur during routine tasks. Slips and lapses are generally the result of fatigue, stress and emotional or sensory distraction (‘Systems Approach’, 2012, cited in Collins et al, 2014).13 Preventable adverse effects refer to harm
from medical care rather than an underlying disease. Much effort has been made to train
Rather than criticism, the focus needs to shift from simply understanding adverse events, to the introduction of measures that will prevent their occurrence. The application of NatSSIPs 2 must ensure that the clinical approach to safety is the same, irrespective of the location, time, and resources available.
surgeons and theatre staff in technical skills but the aspects of non-technical skills – namely teamwork, leadership, situational awareness, decision making, task management and communication – have long been neglected (Oppikofer and Schwappach, 2017).15 Panesar et al ’s (2011)16
earlier study
suggested that these non-technical traits – such as better teamwork and communication in the operating theatre – reduce risk, improve staff well-being and mental health, reduce staff turnover, and reduce delays and glitches in the surgical process. They are key to a safe working environment. This theory was also supported by Joy et al (2011), cited in Oak et al (2015),17
as
they found that formal training in non-technical skills, conducted in simulator laboratories and classrooms, have been shown to improve patient
Number of Never Events that have occurred across NHS England NE Date range
Wrong Site Surgery (Tooth/Teeth removed) April 2012 - March 2013
(NHS England, 2013) April 2013 - March 2014
(NHS England, 2014) April 2014 - March 2015
(NHS England, 2016) April 2015 - March 2016
(NHS Improvement, 2017) April 2016 - March 2017
(NHS Improvement, 2018) April 2017 - March 2018
(NHS Improvement and NHS England, 2019) April 2019 - March 2020
(NHS 2020) April 2020 - March 2021
(NHS Improvement and NHS England, 2021) April 2021 - March 2022
(NHS Improvement and NHS England, 2022) April 2022 - August 2022
(NHS England, 2022) Table 1. 20
www.clinicalservicesjournal.com I April 2023
83 (21) 98 (22) 124 (27) 179 (33) 189 (46) 175 (28) 226 (40) 142 171 73
Wrong implant/prosthesis
42 54 40 59 53 63 47 30 47 17
130 134 102 107 114 102 101 80 98 43
outcomes – but there is often resistance from operating theatre teams. Craig et al (2012), cited in Oak et al (2015),17
suggested that communication errors are the most common cause of adverse events in healthcare. It is often noted that the information does not reach the right person, or is inaccurate, or remains unresolved until they become critical, and Patel et al (2014)18
suggested that
adverse patient outcomes are frequently due to substandard non-technical skills among surgical staff.
Delphi Study methodology The approach to this research was based on one Delphi round where twenty-two NHS England Trust expert theatre managers, matrons and educators were asked for their opinion on a series of questions. Of the 223 NHS Trusts in England (King’s Fund, 2021),19
only 157 NHS Trusts
have operating theatres (Supporting Facilities Data, 2019/20 cited in NHS England, 2020).20 Across seven separate regions, there are
Retained foreign object post procedure
a total of 3,282 operating theatres. For the purposes of the Delphi study, a decision was made to purposefully reduce the number of Trusts and operating theatres. The total number of Trusts included in the Delphi was reduced by twenty-one. This gave a new total of 136 Trusts with 2,918 operating theatres. The rationale for excluding the total number of Trusts from the audit by twenty-one was fully explained in my previous report, published in the March edition ofThe Clinical Services Journal. The aim of this approach, using a Delphi
technique, is to add to existing knowledge from previous research by a dialectic consensus opinion, while seeking a potential solution and negotiation through which a decision could be made by NHS Improvement, which would incorporate the findings from the study. The final Delphi study was sent to all
participants on the 27 December 2022. All responses were recived back on the 24 January 2023. Put simply, the intention for the final Delphi study was to: l Establish the level and delivery of training on the WHO Surgical Safety checklist required.
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