Patient safety in surgical care

Patient safety in surgery has never had a higher profile or more attention in the professional press than it has currently. The science of patient safety and additional human factors science continuously adds to the body of knowledge. Added to which, every professional working in surgical care – wherever that is delivered – has regular reminders, via the WHO Surgical Safety Checklist, of our fallibility and the need for constant checks to ensure patients are safe in our hands. Sadly, it is proved over and over again that we are still found wanting and during 2012/2013 there were 255 never events reported which occurred during surgery.

Following the publication of the never events policy framework in November 2012, the NHS Commissioning Board set up a task force to ‘look at surgical never events in order to make sure that these events are eradicated from NHS Surgery’. The report of their deliberations and recommendations entitled Standardise, educate, harmonise1 was published at the end of February 2014. It makes salutary reading and should be mandatory reading for everyone involved in surgical care. If implemented, as they recommend, it will have a substantial effect on every operating theatre and everyone delivering surgical care – wherever that may be, in the NHS and beyond, in England.

The taskforce concluded that to achieve a continual reduction in harm, we must reduce variation in practice, promote learning from our mistakes and from improvement activities, and continue to promote organisational and professional responsibility. It has proposed a strategy of three interlocking elements: