Call for action following latest 'never events' report

The Association for Perioperative Practice (AfPP) is calling for action to be taken after a recent report suggests little progress has been made to prevent errors within the perioperative environment.

The patient safety charity made the call following the release of NHS Improvement’s latest Never Event report; Provisional publication of Never Events reported as occurring between 1 April and 31 December 2019, which revealed an alarming 81% (284) of the never events recorded happened while a patient was on the operating table.

In total, 350 ‘serious incidents’ met the criteria for a never event, an incident that is considered to be of a serious nature that is wholly preventable due to guidance or safety recommendations that provide strong systemic protective barriers.

176 related to wrong-site surgery, 37 to wrong implants or prosthesis, and 71 to foreign objects being retained post-procedure; figures which Dawn Stott, CEO of AfPP states are “alarming” considering standards and guidance have been introduced to reduce their occurrence:

“We know that minor incidents will never be 100% preventable due to human error, but measures exist that can reduce the occurrence of such serious incidents, so the fact that figures remain high raises concern.

“We will always praise our fellow healthcare professionals for their hard work, integrity and transparency when reporting these serious incidents, but as an organisation focused on improving patient safety, it is hard for us to not be alarmed by the slow pace of progress.

“The data in this report is provisional, but with figures suggesting we’re heading for a similar rate of incidents to last year’s report, it’s clear that action needs to be taken to review whether systematic changes within hospitals to improve patient safety have occurred.”

The previous year’s NHS Improvement Provisional publication of Never Events reported as occurring between 1 April 2018 and 31 March 2019, comprised 496 serious incidents that met the criteria of a never event; 207 of which were related to wrong-site surgery, 104 to foreign object retained post-procedure, and 63 to wrong implant or prosthesis.

While figures are higher overall, the nine-month report for 2019 has a similar month-by-month figure in comparison to the twelve-month report for 2018/19, suggesting slow progress.

Dawn states, however, that the slow pace is not about apportioning blame, but about learning from errors and improving the culture in which teams are working;

“Pointing the finger and allotting blame isn’t the way forward. Staff are under increased pressure due to a variety of factors, and the systems, processes, and environment around them are not always supportive.

“Never events are different from other serious events in how they arise, and we believe that if we want to improve patient safety, we need to focus on improving systems, processes and culture first.”

A recent survey carried out by the association reinforced claims that the culture within the perioperative environment is having a negative effect on patient safety.

Of the 712 UK theatre practitioners that took part, over three quarters (86%) admitted they were concerned about the effect negative cultures were having on patient and staff safety.

What’s more, 39% of theatre practitioners stated that they were often asked to do things outside of their scope of practice, putting patients at increased risk of being subjected to a never event.

Lindsay Keeley, patient safety and quality lead at AfPP said: “The survey highlighted that there’s a need to take action now if we are to support the healthcare profession in reducing the occurrence of never events.

“It has become clear that receptive team culture, a strong leadership team and better support for staff is what will help to reduce the risk of a never event occurring. It’s vital that those in leadership positions begin to understand the contributory factors in the recurrence of never events and the challenges faced by staff.

“What is promising is that there are practitioners who are developing new, practical and simple solutions every day that can support other team members and can be used within theatres across the country.

“One example is Rob Tomlinson’s introduction of the 10,000 Feet initiative – a safety initiative designed to cut through noise and distraction within the theatre environment, particularly at critical points of the patient’s journey.

“If correctly implemented, initiatives like this can cut through the hierarchies that stop people feeling unable to speak up when they see something that shouldn’t be happening, thus reducing the occurrence of never events 

“We of course need to be mindful that there will always be challenges within perioperative practice in the form of interruptions and distractions, but the key is how as practitioners we engage with this to recognise and reduce never events.”