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Cutting Out ‘Never Events’: Surgery Checklists to Spread from Operating Theatre into Emergency Wards

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02 Aug 2014

It is known that ten to 15% of patients admitted to hospital experience an adverse event, but more than half of those related to surgery don’t actually occur inside the operating theatre. Emergency admissions are associated with the majority of complications, including incorrect diagnoses, inappropriate or unnecessary investigations and wrong or delayed treatment, mirroring some of the recent concerns raised by the National Institute for Health and Care Excellence (NICE) on ‘red flag’ events.

Following the successful introduction of the World Health Organisation (WHO)’s intra-operative checklist, the UK’s oldest Surgical College has just received funding to trial a surgical checklist outside the operating room during emergency ward rounds. The initiative has already been endorsed by one of the biggest proponents of safety checklists, airline pilot Martin Bromiley, who lost his wife in 2005 during a routine operation which went tragically – but avoidably – wrong.

The Royal College of Surgeons of Edinburgh (www.rcsed.ac.uk); which recently opened its first-ever base of operations in Birmingham to cater for the 80% of its UK membership based in England and Wales; today announces it has secured funding from the Health Foundation (www.health.org.uk/shine), an independent charity working to improve the quality of health care in the UK.

The £75,000 grant will support RCSEd’s extension of its unique training system ‘NOTSS’ (Non-Technical Skills for Surgeons) developed with the Univeristy of Aberdeen; now also used in the US, Australia and Japan; alongside the WHO’s safety checklist – both proven to dramatically improve outcomes and decrease the likelihood of adverse events – to explore, for the first time, their success outside the theatre. Britain’s homegrown NOTSS remains the world’s only behavioural marker system developed by surgeons for surgeons.

Based on a model similar to those used in the aviation industry to test pilots’ cognitive skills (such as communication and teamwork abilities) the NOTSS system and WHO checklists are designed to reduce the margins for human error. Emergency rounds where the consultant; usually accompanied by nurses and junior staff; personally assesses sometimes 40 to 60 acute patients in a day in between performing surgery, exemplify the kind of high-pressure situation where human factors can play a part in incorrect clinical decision-making. Problems could vary from poor documentation to misunderstandings leading to at best superfluous tests and scans and, at worst, inappropriate treatment or surgery. These can result from a variety of simple human failings including tunnel vision, cognitive bias (illogical or irrational judgment influenced by inaccurate perceptions), lack of team cohesion or leadership, to name a few.

A number of new studies presented at the RCSEd’s recent Presidential Meeting on the theme of Emergency Surgery illustrated the importance of systematic checks to reduce human error:

  • In the case of identifying female patients of who needed treatment to prevent blood clots (Venous Thromboembolism, or VTE), the use of a simple proforma to record contraceptive use at one hospital’s trauma admissions increased record-taking from 17% to 100% and identified that 2/3 (66%) of patients would have been vulnerable to this potentially fatal condition.
  • Similarly, the addition of another straightforward check increased accuracy of nasogastric intubating (which if done incorrectly is classed as a ‘never event’) at another hospital from just a third (33%) following official guidelines to 100%.
  • Yet another hospital saw over 150% improvement in documentation regarding urethral catheterisation (infections resulting from this account for 40% of all hospital-acquired infections) by simply incorporating a standardised ‘reminder’ sticker.

 One of the strongest proponents of the safety checklist concept is airline pilot Martin Bromiley, who lost his wife Elaine after a routine operation went tragically, yet avoidably, wrong. He took the experience as the motivation to create the Clinical Human Factors Group (www.chfg.org), dedicated to reducing avoidable errors in hospitals and building on the wealth of safety experience from his aviation career. He says;

I realise that what happened to my wife is unbelievably common, it’s called normal human error. Yet through my background as an airline pilot I also know that developing systems and standardised procedures can give multiple opportunities to catch error before it becomes harm. I feel it's really important to be extending proven safety check systems from the operating room onto the ward - just as an aircraft is dependent on every crew member, ground staff and air traffic control, patients are dependent on absolutely very member of the hospital care team, from OR surgeons to ward nurses and everyone in between. This will be a great step forward in stopping 'never events' completely.”

The project’s aim is to test an educational system that can assess surgeons in areas of communication, situation awareness, decision making and leadership to ensure that surgical rounds are documented effectively, safety improved and patient care managed efficiently. In turn this may also reduce the incidents of ‘never events’ - serious, largely preventable patient safety incidents, such as wrong site surgery or retained foreign object. The WHO checklist alone, which covers the confirmation of information such as patient identification, anaesthesia safety and even sponge count, has been shown to reduce complications by up to one third and overall mortality from surgery by close to 50%.

According to consultant general and upper GI surgeon Simon Paterson-Brown, Council member of the Royal College of Surgeons of Edinburgh and Chairman of its Patient Safety Board;

“I’m thrilled to be working closely with SHINE on a project which could help revolutionise emergency surgical ward rounds. There are currently no available checklists for any surgical specialties devised for this purpose, and particularly not for use on emergency surgical patients. The NOTSS system is both innovative and unique in that it was developed entirely by surgeons for surgeons, underpinned by psychologists experienced in studying human factors. Although checklists have been developed successfully for medical ward rounds with good results, there are significant differences between surgical and medical evaluations which need to be addressed. It is therefore essential that the non-technical behaviours associated with high quality surgical ward rounds are understood.”

Through its SHINE grant, the Health Foundation is supporting 23 teams with outstanding ideas to tackle challenges within the health service, by providing funding to run and test their quality improvement ideas, and by assessing the impact of and evaluating the effectiveness of their innovations. Dr Jane Jones, Assistant Director at the Health Foundation, says:

“This is the fourth round of the Shine programme, and we are delighted to be working with 23 new teams from across the health service. We are excited to see how these teams and new approaches can deliver better health care by addressing the challenges of patient safety, person-centred care and improving quality whilst reducing costs.”


About The Health Foundation

The Health Foundation is an independent charity working to improve the quality of health care in the UK. It supports people working in health care practice and policy to make lasting improvements to health services. Its members carry out research and in-depth policy analysis, run improvement programmes to put ideas into practice in the NHS, support and develop leaders and share evidence to encourage wider change. Its aim is for the UK to have a health care system of the highest possible quality – safe, effective, person-centred, timely, efficient and equitable.For further information about Shine visit the Health Foundation website www.health.org.uk/shine


About The Royal College of Surgeons of Edinburgh

RCSEd was first incorporated as the Barber Surgeons of Edinburgh in 1505, and is the oldest surgical corporation in the world with memberships approaching 25,000 professionals in over 100 countries worldwide. The College promotes the highest standards of surgical and dental practice through its interest in education, training and examinations, its liaison with external medical bodies and representation of the modern surgical and dental workforce. It is also home to the UK’s only Faculty of Surgical Trainers, open to all those with an interest in surgical training regardless of College affiliation. Find RCSEd on Twitter www.twitter.com/RCSEd and on Facebook www.facebook.com/rcsed

The College is based at Nicolson Street, Edinburgh, EH8 9DW and can be reached on (0)131 527 1600 or mail@rcsed.ac.uk. In March 2014, a new base opened in Birmingham, catering to the 80% of the College’s UK membership who are based in England and Wales.

For all media enquiries please contact the Communications Team on +447467 485145 or email comms@rcsed.ac.uk 


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