Operating theatres


of the SSC is key. Conley, Singer and Edmondson (2011) concluded, following a study of five hospitals, that engagement of leadership was seen as a key factor in the success of the SSC adoption (cited in Barimani et al, 2020)14 Therefore, hospital leaders need to work on staff’s perception and resistance to change, by educating staff that the hospital’s priority is one of patient safety. Gillespie et al’s (2018)8 Australian study stated that the most significant barriers to using the SSC, as recommended, were limited knowledge about timing, a lack of clinical leadership and dissonant attitudes. NHS England’s 2015 National Safety Standards for Invasive Procedures,15


which was published on 7


September 2015, stated that 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 report published in 2014 advised the development of high-level national standards of operating department practice that would support all providers of NHS funded care to develop and maintain their own, more detailed, standardised local procedures. The group tasked with creating these standards have named these ‘National Safety Standards for Invasive Procedures’ (NatSSIPs) and ‘Local Standards for Invasive Procedures’ (LocSSIPs) The then director of patient safety, Dr. Mike


Durkin, stated: “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”. (NHS England, NatSSIPs, 2015,)16


It can be argued, to a degree,


that the introduction of NatSSIPs/LocSSIPs, and harmonisation with the WHO checklist, have been positive, as it has led to a slight reduction in two of the three surgical never events. But should the current list of intra-operative


never events be expanded to include non-airway surgical fires? Keeley (2020)17


categorised


surgical fires as either airway or non-airway. Early research by Bruley (2004)18


concluded that


“surgical fires are a preventable hazard”. This was five years prior to the WHO surgical safety checklist. So why was the decision made not to class a surgical fire as a never event? The Association for Perioperative Practice (AfPP) has a dedicated section in the 5th edition of Standards and Recommendations for Safe Perioperative Practice (2022)19


for the risk


management of fire prevention. There have been numerous global papers published on the benefits of the surgical safety checklist, but how is training captured and how often is training delivered to the users? Close et al ’s (2017)20


study, at twenty hospitals


in Madagascar, suggested that training must address local needs and culture to overcome challenges. Their three-day training programme enabled changes in both personal behaviour and organisational practice that were sustained at three-four months. The Wali, Halai and Koshal (2020)21


study found


that participants advocated regular re-training and incorporation of the training into the local induction programme. Kilduff et al ’s (2018)22


study reported that the UK undergraduate surgical safety checklist training does not meet the minimum standards set by the WHO. One of the Delphi study questions sought to know what the current state across the NHS is with regard to training on the WHO surgical safety checklist. Feedback is important for effective learning, so that ways to improve practice can be resolved. Honest feedback is an essential part of the communication process and cyclical learning. It may lead to an improvement in performance at all levels. NHS England (2022)23 reported that a new national NHS ‘Learn From Patient Safety Events’ (LFPSE) is in the final stages of development. It is thought that it will allow for new safety issues to be identified and acted upon, on an NHS-wide scale, ensuring providers across the country take action to reduce the risk. The plan is to launch phase one from mid 2023. A question to consider is one of ‘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).24


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).24,25 From April 2016, patient safety became part of NHS Improvement (NHS England, 2016) 26


and,


for transparency about patient safety incident reporting, the NHS has published never event


List over-run 18.84% Culture 18.84% Staff want to go home 23.19% All members of the team are not available 26.09% This step is not seen as important 11.59% Other 1.45%


Figure 2 – Why do you think the debrief is missed?


20 www.clinicalservicesjournal.com I March 2023


Ensure that the WHO checklist is a mandatory annual training requirement for all staff that work in theatre 42.86% Take disiciplinary action against the frequent non-compliant staff 14.29% Learn from other organisations that complete all five steps 36.73% Other 6.12%


Figure 3 - How NHS Trusts can challenge and support with the perceived barriers?


Strongly agree 45.45% Agree 36.36% Somewhat agree 13.64% Neither agree nor disagree 4.55% Somewhat disagree Disagree Strongly disagree


Figure 4 - Does the NHS need to revise how the delivery of the SSC is undertaken?


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