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Surgeons join forces to prevent Never Events

Theatre teams in the Wessex region have signed up to four key pledges to prevent future Never Events, particularly around wrong-site surgery.

The clinicians including surgeons, nurses, operating department practitioners, quality/risk leads and commissioners unanimously agreed to sign up to the pledges after a one-day conference which focused on surgical Never Events.

They have committed to improve both processes and culture within surgical teams in a bid to prevent future cases – and a leading consultant surgeon is confident that never events will be eliminated.

The Wessex conference (held at The Ark, Basingstoke in June 2018) was attended by more than 100 clinicians and was jointly hosted by West Hampshire CCG, North Hampshire CCG and Hampshire Hospitals NHS Foundation Trust (HHFT) as part of the Local Care System.

Mr Myrddin (Merv) Rees, Consultant Surgeon and Medical Director (Clinical Development) at HHFT, chaired the conference.

He said: “My commitment and determination to eradicate ‘Never Events’ was matched by delegates representing all the acute and elective Trusts in Wessex.  

“It is unique in my 30-year experience as a consultant surgeon to obtain unanimous agreement on all the conclusions.  I am not alone in believing that when these pledges are implemented ‘wrong side surgery or procedures’ will be eliminated.

“The more didactic talks in the morning set the scene and provided a reference as to what is happening and what would constitute best practice.  

“The afternoon, held un the ‘Chatham House Rule’, was devoted to an honest presentation from all Trusts of real events.  

“There was an open and honest debate regarding the lessons to be learnt which culminated into four pledges.”

Joanna Clifford, a Registered Nurse and Senior Quality Manager at West Hampshire Clinical Commissioning Group, said: “It was a really productive day and everyone was absolutely determined to eradicate surgical Never Events.

“Delegates genuinely felt they could implement change as a direct result of what our speakers said, which is excellent.  We’re looking forward to seeing how these pledges will have an impact on patient safety and fostering positive cultures within our surgical teams.”

Between 1 April 2017 and 31 January 2018, there were 393 Never Events across NHS Trusts in England – 44% involved wrong site surgery and 25% were retained objects.
Fran Watts, Patient Safety Lead at NHS Improvement spoke about data and incidents across the country.

Local Consultant Surgeon Andrew Miles, who is Regional Director for Professional Affairs at the Royal College of Surgeons, talked of the culture within theatre theatres comparing them to the flight deck of a plane.

He warned delegates: “If anyone says ‘I am concerned’, no matter how junior they are, you should listen to them.”

Consultant Anaesthetist Juliette Kemp told how she used the WHO checklist to create Local Safety Standards for Invasive Procedures at HHFT and why the Trust now has a specific checklist for orthopaedic procedures.

One of the most insightful presentations came from Consultant Urological Surgeon Kevin Turner, Visiting Professor at Bournemouth University, who raised the concept of the ‘second casualty’ of a Never Event – namely the lead clinician.

Many of those present had not fully appreciated the impact of a Never Event on the clinicians involved and how they need to be supported in a blame-free culture so everyone can understand how the event happened and prevent future mistakes.
This concept was dramatically brought to life with stories of Never Events from local clinicians who bravely shared their personal experiences.
 
Pledge 1:  Laterality to be indicated at every stage of the process
It was a unanimous pledge by all in the room that wrong side surgery/procedure could, and should, be stamped out in the wider Wessex region. We agreed that clinicians should write the correct side in their notes, be it left or right.  They should book the procedure with the correct side clearly labelled and the consent should be taken with the correct side documented.  Furthermore, when booking the operating list we agreed that should the laterality not be indicated clearly, this should be challenged and rejected.

Pledge 2:  Marking to be accurate, permanent and visible after draping
On the day of a procedure we agreed the correct side should be clearly marked and still visibly clear when the patient is draped.  (Even internal procedures such as ureteric stenting, the correct side could be marked by a radiopaque marker on the skin or by a permanent mark on the thigh that will be visible in the lithotomy position)
We all agreed that in theatre the team brief should be specific, to the point and shared by everyone.  During the WHO process, laterality should match up on the consent form, notes and the marking confirmed by the surgeon in charge and agreed by all team members.

Pledge 3:  We will build a supportive, open and transparent team environment
It was agreed, and borne out in the evaluations and pledges, that building a team in a supportive environment will ensure that patients are less likely to be exposed to inappropriate/avoidable errors.

Pledge 4:  The ‘second casualty’ will be supported
Following an excellent talk by Dr Kevin Turner, it was accepted that we should all agree to support the “second casualty” of a Never Event, i.e. the clinician and team involved in the event. We agreed that this should be approached in a non-blame discussion to highlight why it occurred to enable avoidance in future.
It was acknowledged that in some instances, some individuals may require further independent support.

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