Perioperative practice
l There is open communication l Good teamwork l We talk about our mistakes and learn from them
l Strict adherence to the WHO checklist l Debrief always offered l Policies in place to support safe practice l A very good patient safety lead l Supportive managers
Reasons for the negative responses included: l Issues are swept under the carpet l Staff concerns are ignored l I have been challenged by the head of nursing for raising staffing concerns
l Staffing issues causing trouble l Complacency, ego trip, bullying
Paul Wheeler described the process of an investigation after a never event, including root cause analysis and the Patient Safety Incident Response Framework (PSIRF). It is important to ensure compassionate engagement and involvement of those affected by patient safety incidents; use system-based approaches to learn from these incidents; and ensure a considered and proportional response to the patient safety incident. He went on to discuss how to develop a
‘culture of safety’ – which included promoting respectful team behaviour and fostering psychological safety by creating an environment where staff feel safe to speak up, report concerns and learn from mistakes without fear of blame. He also highlighted the importance of structured safety tools such as WHO’s safe
5. Implant use 6. Reconciliation of items 7. Sign out 8. Debrief/handover
Despite the fact that the safety standards have been in place for some time, a survey of the delegates revealed that many of the audience were yet to receive training on NatSSIPs – 49 said they had received no training, while 37 said they had. The survey demonstrated that there is a need for further education in this area. Other highlights of the conference, included*:
Alex Duke, AfPP CEO
surgery checklist, including effective briefings, as well as the National Safety Standards for Invasive Procedures (NatSSIPs). Originally published in 2015, the standards
were revised in 2023. NatSSIPs 2 has less emphasis on ‘tick boxes’ or rare ‘Never Events’ and now includes “cautions, priorities and a clear concept of proportionate checks based on risk”. The document describes the need to “consider human factors with systems thinking, culture, psychological safety and teamwork” to underpin its implementation. The standards include an update of the WHO
‘Five steps to safer surgery’ (Team Brief, Sign In, Time Out, Sign Out and Handover/ Debrief), and now include three more steps in the Sequential Standards (Steps). The ‘NatSSIPs 8’ include: 1. Consent and procedural verification 2. Team brief 3. Sign in 4. Time out
l State of play: leadership for the future we need, by Ed Gillespie, writer, activist, podcaster and futurist.
l Beth’s story: the importance of speaking up and challenging in teams, by Clare Bowen, Trustee, Clinical Human Factors Group.
l Oliver’s story: avoidable deaths and the importance of reasonable adjustments, by Paula McGowan OBE
l Daisy Ayris Lecture: fixing theatre culture and behaviours, by Scarlett McNally, Consultant Orthopaedic Surgeon, East Sussex and Deputy Director, Centre for Perioperative Care.
Commenting on the success of the conference, AfPP’s CEO, Alex Duke, said: “What makes our conference so valuable is not only the quality of the sessions, but also the opportunity it provides for networking and the sharing of knowledge and experiences among colleagues from across the UK. By creating a space where perioperative practitioners can connect, learn from one another, and reflect together, we strengthen our collective ability to drive improvements in practice and patient safety. This combination of expert insight, open dialogue, and professional collaboration is what makes the conference such a powerful platform for change.”
*CSJ will be sharing additional insights from the conference programme in the next editions.
Reference 1. Porath C, Pearson C. The price of incivility. Harv Bus Rev. 2013 Jan-Feb;91(1-2):114-21, 146. PMID: 23390745.
To sign up to the AfPP Behaviours Charter and receive a poster, scan the QR code below
CSJ
Prof. Scarlett McNally discussed the impact of theatre cultures and human factors October 2025 I
www.clinicalservicesjournal.com 21
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68
