‘Never Events’ and the safety barriers
The operating theatre is a rather unique department within a hospital. Patients may need life or limb saving surgery or they may just be looking forward to having a new hip or knee which will give them a new lease of life. Surgery does however have the potential to cause unintentional serious harm or even death to patients. The operation itself, the unpredictability of surgery and the amount of equipment and consumables means it is no wonder there is the potential for things to go wrong. However there are a vast array of systems, policies and procedural safety drills that aim to reduce the risk of harm as much as possible.
Whilst there are many thousands of operations and procedures carried out each year, catastrophic events are proportionally rare today, but not unheard of. Nevertheless, a number of so-called ‘never events’ have been identified. These are defined as incidences that are ‘wholly preventable’ providing staff follow and adhere to the systematic processes which incorporate barriers to stop these events from occurring in the first place.
These barriers should start way before the patient enters the theatre suite. The patient’s name, date of birth and hospital/NHS number should be on their identity band which is usually positioned around their wrist. If the surgery is being performed on their arm, it is good practice to ensure the identity band is not on the operative arm and an additional one should be placed around their ankle. Once the patient is under a general anaesthetic or has been given sedation, the identity band becomes the only means to confirm the patient, and these personal details are particularly important during theatre checks and in the event blood products need to be transfused.
The consent process for the proposed procedure should involve the surgeon (or a member of their team), the patient or their advocate alongside any relevant scans or x-rays. At this point, any surgical site marking should be done with an indelible pen so the mark is still visible after skin preparation.
Pre-operative checks are carried out a number times by numerous people and at each check, it is hoped that any discrepancy is identified and more importantly rectified. Patient details, their planned procedure, allergies, internal metalwork or prosthesis and their fasting status are just some of the checks that are made. Additionally, women of childbearing age admitted for elective surgery are offered a pregnancy test on the day of their procedure and the result is documented on the checklist. If it was found to be positive, a discussion would take place with the patient and the surgeon to determine if the surgery should go ahead. It is generally accepted that elective, non-urgent procedures are postponed due to the potential risks to the foetus. For emergency ‘life or limb’ saving surgery, pregnancy tests are not carried out.
At my particular Trust, the checklist process is completed
- On the ward
- By the person collecting the patient
- By the anaesthetic nurse/ODP in the anaesthetic room or waiting bay
- By the session anaesthetist before they start the anaesthetic
- And finally when the patient is actually in the operating theatre a check is completed when a ‘time out’ is conducted with the whole team involved
- If any procedure requires the use of x-ray, the radiologist will always refer to the checklist to determine the patients pregnancy status
The final ‘time out’ check is done before any skin preparation or draping is done and it includes the registered scrub person and the operating surgeon, both of whom are accountable and have a duty of care to the patient. At this point, the patient’s details including the proposed operation should be displayed on a white board in a prominent area for everyone to see. Everyone within that team should feel they have the confidence to speak up if they think any part of the ‘time out’ is incorrect.
The relevant ‘never events’ in operating theatres are wrong site surgery and retained instruments post operation. Wrong site surgery may include operating on the wrong patient, and can include, for example, operating on the wrong limb, organ, eye, tooth and also the wrong level in spinal surgery. Within this, inserting the wrong prosthesis or implant is also considered to be a ‘never event’.
Retained instruments or retention of a foreign object can include swabs, needles and guide wires. These are considered to be subject to a formal count or check which should be undertaken by the scrub person along with another appropriate member of the team. Instruments are counted and checked ensuring the tray inventory corresponds with the actual instruments present. Swabs, needles and blades are counted and a tally should be displayed in a prominent area to act as an aide-memoire. Whilst it is good practice to always be aware of the location of all the instruments and consumables during the operation, an official count should be done prior to commencement of surgery, prior to closure and again once the surgery is finished.
Despite the implementation of national guidance, such as that from the World Health Organisation ‘WHO’, raising awareness of ‘never events’, they still occur. There may be many reasons why they happen or have come close to happening. Standardisation of operating department procedures alongside educating and training staff to bring about a culture change to theatres so everyone feels they can speak up, can go some way to reducing errors but realistically these errors cannot be fully eliminated.