UK innovation supports safer practice

The publication of a pilot study by the World Health Organization, in The New England Journal of Medicine (NEJM), which reveals that millions of lives can be saved on the operating table using the Surgical Safety Checklist, has sparked a direct response from the National Patient Safety Agency (NPSA). Its decision to issue an alert that requires healthcare organisations in England and Wales to implement the Surgical Safety Checklist for every surgical patient by February 2010, demands that hospitals invest in patient safety. But within industry, we know that many leading hospitals have already recognised this and are already putting safety first, by incorporating technology that helps prevent the mistakes and human errors that can cost lives. It is difficult to recognise that people make mistakes – but they do, and mistakes in healthcare can lead to the death of a patient. The World Health Organization’s pilot study ran in eight hospitals around the world from Tanzania to Toronto and collected data from non-cardiac patients, concluding that a checklist can cut the death rate from surgery from 1.5% to 0.8% (a 47% reduction) and the complication rate from 11% to 7% (a 36% reduction). Based on these figures, with an estimated   eight million operations performed every year in England and Wales, the checklist could save up to 56,000 lives a year. From discovering that the wrong limb has been removed, to incorrectly administering medication, or even finding that equipment has been left in the body after surgery, the complications and potential fatalities because of human error are startling. But how do we prevent mistakes? One way has to be the checklist, which is simply 19 steps that should be completed before, during and after surgery. It’s a similar system to that used in aircraft cockpits before take off, ensuring that the whole team checks everything, every time. At the moment, it is just a piece of paper, another piece of administration for our overworked NHS teams. But by using technology to prompt and record the process, keeping patients safe from error can become a transparent, fast and monitored process. With so many lives at risk because of individuals’ mistakes, it is essential that hospitals across the UK follow the lead of those surgeons and staff who have already introduced checking systems into their operating theatres and wards, with similar reductions in fatalities and complications. In the UK’s medical technology hub, the West Midlands, companies have been working with hospitals to develop devices to help the NHS implement the checklist quickly, effectively and actually make life easier for staff and surgeons.

 Innovating for safety

Birmingham’s Heartlands Hospital has been a pioneer in the field, piloting an effective and error-proof way of replicating the paper process using technology. The Safe Patient System includes an electronic wristband using passive radio frequency identification (RFID) to improve the identification processes, patient safety and staff efficiency, saving money and reducing the risk of litigation. The company is already in discussions with the NPSA to combine the technology with the Surgical Safety Checklist, making it easier for surgeons and staff to adopt and use. New mobile technology called Near Field Communication allows a user to merely touch their mobile phone against an electronic tag to initiate a task or receive information. Specialists Sero Solutions are already looking at ways in which this technology could help all members of a team record their feedback or patient interactions. By touching a tag with a mobile device, a URL of a Mobile Internet session on a PDA device could be sent. Each user could contribute their own feedback on the checklist, and it could be viewed for completeness before each stage of the surgical procedure. Such innovative technology ensures the checklist approach and ethos can be applied across all areas of the hospital, not just within the operating theatre. A patient’s entire journey through the hospital, including every interaction, can be checked and recorded. A specific risk to patient safety has been identified by the award-winning Metrasens (a spin-out from defence technology and security company, QinetiQ) in MRI scanning units. The central magnet in an MRI scanner has such a powerful attraction to ferrous metals, that it can hurl a porter’s trolley through a room, or rip a device from the body of a patient. According to a recent US study, incidents occur once in every 1,000 scans, so Metrasens developed a system that immediately alerts clinicians to any trace of ferrous metal entering the MRI scanning suite. With the wider patient safety issues in mind, investment in the Institute for Digital Healthcare at Warwick University’s £12.5 million digital lab, brings together technology experts from the Warwick Manufacturing Group, researchers from Warwick Medical School and key NHS staff to translate scientific advances into improved public health and patient care. In addition, the Heart of England NHS Foundation Trust is developing the Hollier Simulation Centre at Good Hope Hospital as a facility to train doctors, dentists, nurses, allied health professionals and multidisciplinary teams across the region – with a focus on safety. By using technology as a safety net, the NHS can ensure that the Surgery Safety Checklist works, that patient safety improves, while enhancing the efficiency of NHS staff and communication. It will also make the effects of the checklist easier to measure. So why look to the US or Europe for inspiration, when the answers are right here?