Patient safety


never events 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.” Slips and lapses are generally the result of human factors – such as fatigue, stress and emotional or sensory distraction (Systems approach, 2012, cited in Collins et al, 2014).28 Over the years, much effort has been made to train 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).35 These traits were stated back in 2011, by Panesar et al (2011)40


and they also suggested


that the non-technical traits, such as better teamwork and communication in the operating theatre; reduces risk; improves staff well-being and mental health; reduces staff turnover; and reduces delays and glitches in the surgical process – which is key to a safe working environment. Speaking up, and being encouraged to do


so, is not easy – as Oppikofer and Schwappach (2017)36


have suggested. Nurses, for example,


may not speak up to a surgeon if they notice a problem, due to fear of being ridiculed for perhaps being incorrect, or the fear of being blamed by a superior. Encouragement of speaking up and creating a climate allowing all members to speak, without the risk of being punished, is therefore a true act of medical leadership. During surgery, all team members must be empowered to stop the surgery if they sense or discover a breach in patient safety.


NHS England Participants – Delphi Study round one


Region London


Southwest Southeast Midlands East


Northwest


Northeast & Yorkshire Total


Table 1.


Number of Trusts 23 22


21


25 18 26 22


157


After the publication of the first global survey on the use of the SSC, by Haynes et al (2009),11 it was clear that this tool, adopted from the aviation industry, would have an increasing impact on patient safety. High Quality Care for All (Department of Health, 2008)41


proposed that a


never event policy be introduced for the NHS in England from April 2009. The NPSA co-produced a set of criteria for defining “never events” and agreed a core list of eight “never events”, alongside a policy framework. A question to consider is: ‘has the NHS


created a stigma instead of learning from one’s mistake? ‘Never events highlight weak areas within an organisation’s safety process and patient safety. Therefore, they are integral for the improvement and development of the NHS system (Sampson, 2018).42 By creating a list of never events, not only is the NHS suggesting that other equally harmful events are not as serious, as they have not made it onto the list, but it can also attach a stigma to these events and creates a culture of blame, as opposed to a culture of learning and openness (MDU, 2016, cited in Reed et al, 2016 and cited in Sampson, 2018).42 From April 2016, patient safety was now part


of NHS Improvement and for transparency about patient safety incident reporting. From April 2014, the NHS published never event data (NHS England, 2016).43


non-technical skills – such as leadership, basic cognition, situational awareness, operative briefing, and communication – all need to be taught and understood by all users. There is still much work needed to address the myth of ‘having the time to perform the checklist’, but this can be overcome by having local champions to help reduce the perceived associated barriers of using the safe surgery checklist. Having tailored specialty-specific checklists that are reviewed every two years, to ensure that they are still meeting the needs of both the patient and the end users, may also increase staff buy- in. There is still much more research needed, to understand if these contributing factors result in patient harm, as well as whether a further second time out would be of benefit.


Delphi Study methodology Thinking about the first round of the Delphi study, a review of the current practice and researched literature will act as the catalayst for further enquiry. The approach to this research is based on three Delphi rounds where 23 NHS England Trust expert theatre managers, matrons and educators are asked for their opinion on a series of questions. Table one details the participants from across NHS England.


Of the 223 NHS Trusts in England (King’s Sampson (2018) summed


up healthcare mistakes by stating that, at any point during patient treatment, a mistake can occur. These often come down to human error. We should learn from our mistakes, but sometimes they are unavoidable and, therefore, should be seen as a learning curve, as opposed to being a disastrous event for the Trust.42 Barimani (2020)33


found no evidence to


suggest that any patient harm has occurred by using the SSC. However, for checklists to work, be successful and to reduce harm,


Fund, 2021),44 only 157 NHS Trusts have operating


theatres (Supporting Facilities Data, 2019/20 cited in NHS England, 2020).45


Across seven


separate regions (see figure one) there are a total of 3,282 operating theatres (See table one). For the purposes of the Delphi study, we chose to purposefully reduce the number of Trusts and operating theatres. The total number of Trusts included in the Delphi was reduced by twenty- one. Table two details the number of Trusts by region and the number of operating theatres. The rationale for excluding the total number of


NHS England Trusts by region and the number of operating theatres


Region London


Southwest Southeast Midlands East


Northwest


Northeast & Yorkshire Total


Table 2. February 2023 I www.clinicalservicesjournal.com 27


Number of Trusts 22 20 15


15 21


22 21


136


Number of operating theatres 512


275 438 524 272 366 531


2918


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