The management of risk is at the heart of health and safety law. In this article, JOHN BEESLEY explores the duty of both employer and employee within perioperative care to ensure reasonable measures are being taken to promote patient safety and welfare of staff.
You could not possibly have failed to notice recent media hype and publicity given to healthcare when things go wrong.
Dirty hospitals, drug errors, anaesthetic awareness, invalid consent, and incorrect surgery performed on patients make news and at the same time horrify the public who put their trust in our care.
A report published by the National Audit Office (NAO 2003) “A safer place to work” indicated within 96% of NHS acute, ambulance and mental health Trusts that in 2003-04 some 885,832 incidents and near misses occurred. If these statistics were not bad enough. when the NAO report “A Safer Place for Patients: Learning to improve patient safety” (2005) hit the national headlines in November 2005 it certainly struck a blow to many of us working in healthcare striving to manage risk and prevent harm to patients. The figures released by the NAO did not make for comfortable reading. In 2004-05 the NAO reported 974,000 incidents and near misses.
The most common incidents reported were patient injury due to falls, medication errors, equipment related incidents, record documentation error and communication failure. In addition, the NAO estimates that patient safety incidents cost the NHS an estimated £2 billion a year in extra bed days. The Department of Health estimates that one in ten patients admitted to NHS hospitals will be unintentionally harmed and around 50% of these patient safety incidents could have been avoided if lessons from previous incidents had been learned.
DUTY
As perioperative carers and professional practitioners we have a duty to understand health and safety laws to ensure that adequate systems are in place within our working environment and clinical practice that minimise risk to patients, the public and staff colleagues. In doing so we can be assured that our first action is always “first do the patient no harm”.
The leading professional body for nonmedical perioperative staff is the Association for Perioperative Practice. AfPP publishes clinical risk standards to inform best practice – one of which is concerned with health and safety: “Personnel working in the perioperative setting are aware of their legal and professional obligations for health and safety. There are systems in place to ensure a safe environment for patients, staff and visitors.”
The reality of working in the perioperative environment is the fact it is potentially a minefield where risk to both patients and staff is much higher than in other healthcare settings. While it is often difficult to acquire data for incidence of untoward events within the perioperative setting, Wilson (1998) reported one district hospital where 32% of all hospital incidents occurred in the operating theatre.
So how seriously do you take your health and safety responsibilities? Do you understand your legal responsibilities with regard to health and safety?
Ignorance of the law is no defence if an unexpected incident occurs and as a result of the incident harm is caused to a patient or a work colleague. Promoting health and safety is everyone’s responsibility within the perioperative setting. We have a duty of care to our patients to promote it. We are contractually bound to maintain health and safety via our employment contracts while we are also accountable via our relevant regulatory codes of professional conduct to minimise risk to patients.
Does your department have a Health and Safety Executive (HSE) laminated health and safety poster clearly displayed highlighting both employer and employee responsibilities as indicated by the Health and Safety at Work Act 1974?
Where is this displayed in your department and when was the last time you read it to ensure you fully comprehend your legal and professional obligations?
When was the last time you reviewed your health and safety responsibilities within your employment contract, terms and conditions? Do you understand the principles of health and safety law because, remember, ignorance will be no defence if you are involved in a safety incident.
COMPLEX MIXTURE
Health and safety laws are a complex mixture of statutory provisions, Acts of Parliament and Statutory Instruments (Dimond 2002). The Health and Safety at Work Act (HSWA) 1974 was the first major statute that provides the legal framework to promote and encourage standards of safety within any work environment. The Act was formulated as a result of one of the worst disasters of the 20th Century, the Aberfan disaster of 1966. At Aberfan, 144 people including 116 children were killed when a colliery waste tip slid down a mountain onto the village, destroying a junior school.
The HSWA provided the framework whereby if negligence is proven it could lead to criminal charges and imprisonment for those found to be negligent. The HSWA therefore introduced the concept of criminal liability. Failure to take reasonable care could result in a criminal prosecution in a Magistrates/Sheriff Court or a Crown Court. Failure to ensure safe working practices could also lead to an employee suing his/her employer for personal injury or in some cases the employer being sued for corporate manslaughter.
The Act also introduced the onus of proof where the fact that an accident had occurred means the onus of proof fell on the employer to prove that he/she had not been negligent. Having adequate traceability systems in place means an organisation can prove how a reusable medical device was decontaminated. This would be essential if a patient was to allege that a post-operative infection was due to the use of a reusable medical device during the operative procedure.
The basic duty of every employer is set out in section 2(1): “It shall be the duty of every employer to ensure, so far as is reasonably practicable, the health, safety and welfare at work of all his employees.”
The act imposes a responsibility on the employer to ensure safety at work for all their employees by taking reasonable steps to ensure the health, safety and welfare of their employees at work. This includes making sure safe systems of work are in place such as safe staffing levels, clinical standards and evidence-based policies.
The Act also places a responsibility on the employee to take reasonable care of their own health and safety and that of others affected by their acts or omissions. Therefore employees must co-operate with their employer so far as is necessary to enable their employer to comply with statutory duties stipulated in the Act. What is reasonable is often decided by employment tribunals or the courts. Dimond (2002) highlighted the fact the law usually requires a risk to be managed “so far as is reasonably practicable. It does not place an absolute duty upon the employer to eradicate all risks from the workplace, but to take all reasonable measures to remove them or reduce the effect of them causing harm to employers and others.”
So how do we as practitioners comply with this in the perioperative setting? • By maintaining and promoting quality standards of care and by adhering to our organisation’s policies, protocols and procedures. If you are currently undertaking a clinical procedure where no such policy or protocol exists to support the procedure “do not do it” until a policy is formulated and in place. This includes first assisting or returning explanted items to patients.
• By keeping yourself up-to-date with your clinical practice you can advise your employer of new developments and recommendations for safe practice. You can achieve this by regularly reading relevant journals and publications.
Under section three of the 1974 Act the employer has a duty of care to persons not in their employment. This duty will cover patients and visitors to the operating theatre such as medical device representatives and students. Does your department have a policy for managing visitors to the operating theatre?
The Health and Safety at Work Act 1974 established two agencies, the Health and Safety Commission (HSC) and the Health and Safety Executive (HSE). The HSC is the agency responsible for advising and authorising research and suggestions and putting into effect the provisions made in the act as well as issuing codes of practice. The HSE is the agency responsible for providing information and advice to the Government and to investigate breaches of the Act. It has powers to serve improvement or prohibition orders on work establishments.
In 2003, West Dorset General Hospitals Trust became the first healthcare organisation to be issued with an improvement notice by the HSE for failing to manage work related stress among its workforce (Cooper 2003). This followed the action of one employee who complained to the HSE. So do you have a stress management policy in place within your organisation?
RISK ASSESSMENTS
The Management of Health and Safety at Work Regulations (MHSWR) imposed a responsibility on the employer to undertake risk assessments in their workplace to ensure that risks are identified and reduced as much as possible. It places an obligation on the employer to actively carry out a risk assessment of the workplace and act accordingly. AfPP recommended (2004) that employing organisations must have systems in place which:
• Identify risks and hazards.
• Formulate solutions to reduce risk where possible.
• Ensure that mistakes and errors are not repeated.
• Ensure that staff are risk aware and proactive in managing risk.
Walker and Stevens (2001) define risk management as involving a two-pronged approach, to identify where there is a risk and formulate where possible solutions to reduce the risk.
The MHSWR regulations stipulate that a risk assessment must be reviewed when necessary and recorded. The record should identify all hazards, and risks and action plans. This is of course the basis for clinical risk management which is an integral part of clinical governance (1998 First class service). As perioperative practitioners we carry out assessments every day such as checking anaesthetic equipment before use and preparing the operating theatre with supplies required for the operating list to run efficiently. But do you ensure you record such activity? Documentary evidence of the person responsible for assessing the risk and completing a checklist will need to be available if an adverse incident involving the equipment was to occur.
The Act also requires the appointment of adequate competent persons who must assist their employer with obligations set out by the statute law. These key people will include the local fire officer, moving and handling co-ordinator, health and safety representative, Control of Substances Hazardous to Health (COSHH) advisor and infection control link.
The Act also requires the employer to provide adequate health and safety training especially on induction and recruitment to a new post. Such training should also be provided when you are expected to use new medical devices or equipment. Advancing technologies in anaesthetic and surgical equipment often sees new devices coming into the operating department on a regular basis and staff using such devices should only use them when they are assessed as competent to do so. Does this occur in your department?
The training should be repeated where appropriate, take account of new or changed risks and take place during working hours. Specific risk assessments must especially be undertaken for new or expectant mothers. Potential hazards to health may include moving and handling tasks, formaldehyde, methyl methacrylate, radiation and some anaesthetic gases.
OBLIGATIONS
The Workplace (Health and Safety and Welfare) Regulations 1992 places obligations on employers to reduce the risks associated with work. The Act addresses the control and maintenance of temperature, lighting, ventilation, cleanliness and room dimensions. A reasonable temperature during working hours in the operating theatre is a minimum of 16°C. Do you monitor environmental temperatures within your theatres? There should be a facility for you to record the room temperature whether you work in an anaesthetic room, operating theatre or post-anaesthetic recovery area. Floor, wall and ceiling surfaces must be capable of being kept sufficiently clean – therefore exposed plaster and damaged wall edges are not acceptable and pose an infection control risk meaning your employer is failing to comply with the regulations.
• Specific hazards to flooring are water spillage especially in scrub up areas and therefore approved notices should be in place warning personnel of the risk and care taken to ensure spillages are adequately cleaned up.
• Rest areas should be fit for purpose with sufficient washing facilities that include adequate shower and toilet facilities. Staff are entitled to suitable accommodation for their personal clothing which means personal lockers should be available to use.
SUMMARY
The emphasis on safety is integral to the patient care we administer as perioperative practitioners every day.
The aim of this article is to help perioperative practitioners understand their obligations with regard to managing clinical risk for nursing patients during their surgical pathway by reviewing health and safety laws affecting perioperative practice. Eliminating all mistakes may not always be feasible as human error will always occur when staff work under pressure for whatever reason.
Clinical mistakes are often less to do with individual practitioners and more to do with a chain of events. However, ensuring robust policies, procedures and protocols are in place that are compliant with clinical governance principles (Scott et al 2004) will ensure that safe systems of work are established.
The National Patient Safety Agency (2004) published seven steps to patient safety and as professional practitioners we should be aware of this guidance to ensure patient care is not being compromised within departments.
Health and safety is not always the most inspiring of topics but if you have a full understanding of health and safety regulations it can certainly empower your clinical leadership skills and ensure that nursing care is maintained for the most important person in our care, the patient.
REFERENCES
1 Cooper K. 2003 Feeling the pressure Nursing Standard August 20, Vol 17, No 49 12-13.
2 Department of Health. First Class Service.
3 Dimond B. 2002 Risk assessment and management to ensure health and safety at work British Journal of Nursing Vol 11, No 21 1372-1374.
4 Dimond. B 2002 Statutory provisions of the Health and Safety at Work Act 1974 British Journal of Nursing Vol 11 No6 396-397.
5 National Association of Theatre Nurses Standards and Recommendations for Safe Perioperative Practice 2004 Risk management 2.1 41 Harrogate NATN.
6 National Audit Office 2003 A safer place to work http://www.nao.org.uk
7 National Audit Office 2005 A safer place for patients: learning to improve patient safety http://www.nao.org.uk
8 National Patient Safety Agency 2004 Seven Steps to Safety www.npsa.nhs.uk/sevensteps
9 Scott E., Summerbell L. 2004 Managing risk in the perioperative environment Nursing Standard April 7 Vol 18 No30 47-52.
10 Walker L., Stevens V. 2001 Accidents don’t just happen British Journal of Perioperative Nursing Vol 11 No 8 342-345.
11 Wilson J. 1998 Incident reporting British Journal of Nursing June 7 (11) 670-671.
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