Hospital Innovations, on the 25 - 26 April, will bring together the key decision makers responsible for the delivery of patient services in the UK.
The rates of error present a significant challenge to those working in the NHS. Mona Guckian Fisher, independent healthcare consultant and immediate past president of the Association for Perioperative Practice (AfPP), looks at near miss events within surgery
Surgery is intended to save lives, enhance functionality and provide a number of other positive outcomes. It is never intended to cause harm; yet unsafe surgical care can cause substantial harm and even death. Patients undergoing surgical procedures are inevitably at their most vulnerable and have an expectation and a right to expect a safe and quality experience.
Yet, accidents happen and unintended consequences are the result for both patients and healthcare professionals. A great deal of time and resource has been committed to exploring patient safety incidents for the purpose of gaining a better understanding of the human factors and causative features of such incidents.
The NHS deals with over one million patients every 36 hours. In 2015/16 there were 40 per cent more operations ('procedures and interventions' as defined by Hospital Episode Statistics, excluding diagnostic testing) completed by the NHS compared to 2005/06, with an increase from 7.215 million to 10.119 million.There were 16.252 million total hospital admissions in 2015/16, 28 per cent more than a decade earlier (12.679 million).1
There is often a gap in understanding amongst healthcare professionals on what constitutes a patient safety incident. A patient safety incident is defined as ‘any unintended or unexpected incident which could have or did lead to harm for one or more patients receiving NHS care’.2 The top four most commonly reported types of incident continue to be: patient accidents (19.2 per cent), implementation of care and ongoing monitoring/review incidents (13.2 per cent), treatment/procedure incidents (10.6 per cent), and medication incidents (10.2 per cent).3
Near miss events
The importance of robust investigation and analysis to determine contributory factors and provide explanations is vital to prevent re-occurrence and learn important lessons. It has to be acknowledged that a great deal of time and resources is generally committed to this process in the healthcare sector, but all too often this lacks the required rigour to uncover the vital truths; thus missing opportunities for life saving change.
It is a recognised fact in the field of risk and safety that the big catastrophic incidents are often the result of numerous small unnoticed and unaddressed issues, often referred to as ‘near miss’ events. A near miss is an unplanned event that did not result in injury, illness, or damage – but had the potential to do so.4 Only a fortunate break in the chain of events prevented an injury, fatality or damage; in other words, a miss that was nonetheless very near.
Reporting on near miss events is known to be less frequent than for actual incidents for the obvious reason that nothing adverse is seen as an outcome. However, near miss events that are captured in the reporting system should be explored and analysed with much greater attention, and this data exploited to provide the foundations for the prevention of adverse outcomes for patients and staff. The aviation industry captures this information and is renowned for investigating near miss reported incidents with the same strict discipline as actual incidents. This industry understands fully the value of this endeavour in the interests of safety. Whist accepting that there are enormous differences between healthcare and aviation this is one point where opportunities are present to see and pursue the similarities.
When incidents occur in healthcare there is often a delay in starting the investigation and creating the time line that is necessary as part of the forensic examination close to the time of the incident; and where recall and evidence are optimal. Any delay in this is a missed opportunity to undertake the factors that need consideration together with the activities of the people involved. Nowhere is this more clearly seen as with the exploration of ‘never events’. Never events are serious incidents that are wholly preventable as guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers.5
Professor Sir Ara Darzi, writing in The Times (February 23, 2016), suggests that surgeons should ‘blush at the incidence of never event in the NHS over the past four years’. He states that ‘these appalling errors bring shame on surgeons’.6
As healthcare professionals we have to be mindful that it is not only the surgeons that are responsible for patient safety in the surgical environment and to this end, perioperative nurses and operating department practitioners (ODPs) have a clear legal, ethical and professional responsibility to apply and adhere to the existing standards of care and available guidance.
Patient safety a public priority
The statistics available on never events provided on 11 January 2017 for the period between 1 April and 31 December 2016 indicate a total of 314 incidents that appear to meet the definition of a never event as outlined in the Never Events list 2015/16. During this period there were 133 wrong site surgeries, 75 retained foreign objects post procedure and 38 wrong implant/prosthesis insertions.7
The NHS in England is one of the only healthcare systems in the world that is open and transparent about patient safety incident reporting, particularly around never events. Patient safety is the foundation of good patient care and is defined as: ‘The avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the process of healthcare’.8 The reference to amelioration of adverse outcomes or injuries broadens the definition beyond traditional safety concerns for many industries up to a category for ‘disaster management’. However in healthcare amelioration firstly refers to the need for rapid medical intervention to deal with the immediate crisis, and also to the need to care for injured patients and to support the staff involved.
Over many decades high profile events, government responses, investigations, enquiries and numerous professional reports have brought patient safety into the forefront of the public domain. We have learned that blame and discipline are an ineffective response to most safety problems. A more appropriate solution is provided by Sidney Dekker who proposes that we need the kind of accountability that encourages learning. He talks about individuals telling their stories, giving their accounts from their perspective of direct or close involvement. This lived experience represents ‘a rich trove of data for how safety is made and broken at the very heart of the organisation’.9
The rates of error and harm continue to present a significant challenge for those of us who work in the healthcare industry and in particular those within the area of surgery. Undeniably, when looking at the latest data on never events there is a huge chunk of responsibility and accountability for all involved in the operating theatre service.
The operating theatre is a complex environment fraught with risk which is managed continuously on a daily basis. There is no denying that managing surgical and anaesthetic services requires skill expertise and a thorough awareness and knowledge of risk, risk mitigation and management. It is imperative that we have the right people with the right skills in place to manage this area of healthcare. Each organisation and operating theatre will have to answer this question individually. Sadly, it is certain that not all will be able to do so in the affirmative.
1. NHS Confederation 2016 Key statistics on the NHS Available from: http://www.nhsconfed.org/resources/key-statistics-on-the-nhs [Accessed 7 February 2017]
2. National Patient Safety Agency (NPSA) What is a Patient Safety Incident? Available from: http://www.npsa.nhs.uk/nrls/reporting/what-is-a-patient-safety-incident/ [Accessed February 2017]
3. NHS England Data Available from: https://www.england.nhs.uk/2015/09/patient-safety-reporting/ [Accessed 7 February 2017]
4. Near Miss Definition Available from: https://en.wikipedia.org/wiki/Near_miss [Accessed 7 February 2017]
5. NHS England Never Events List 2015/16 Available from: https://www.england.nhs.uk/patientsafety/never-events [Accessed 7 February 2017]
6. Guckian Fisher M 2016 Never in a month of Sundays Journal of Perioperative Practice 26 (5) 94
7. NHS Improvement 2017 Provisional publication of Never Events reported as occurring between 1 April and 31 December 2016 Available from: https://improvement.nhs.uk/uploads/documents/NE_data_provisional_report_... [Accessed 7 February 2017]
8. Vincent C 2011 The Essentials of Patient Safety (p4) Available from: http://www.chfg.org/wp-content/uploads/2012/03/Vincent-Essentials-of-Pat... [Accessed 7 February 2017]
9. Dekker S 2014 The Field Guide to Understanding Human Error 3rd Ed Routledge