Today’s healthcare professionals are in the vanguard of the much needed change in how patient care is undertaken and evaluated. Between 1 April 2016 and 31 January 2017, there were 365 reported perioperative incidents. Of these 351 were categorised as Never Events; preventable incidents that can include such things as wrong site surgery, wrong implants, wrong route administration of medication, misplaced Naso or orogastric tubes and retained foreign objects to name but a few (NHS Improvement, 2017).
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Never Events can be seen as indicators of weakness in processes, communication, and praxis. It is therefore vital that practitioners learn from present literature on such events and use this information to change organisational systems for patient safety. The development and implementation of the World Health Organisation (WHO 2008) Safer Surgery Checklist has provided a systematic process for reducing risks in surgery. Combining the use of this checklist with strengthened communication and training staff to appraise potential human errors, will increase their situational awareness and emotional intelligence within this healthcare environment.
National Safety Standards for Invasive Procedures (NatSSIPs NHS England, 2015) build on this further by providing a framework for organisations to continually evaluate the care provision delivered through Local Safety Standards for Invasive Procedures (LocSSIPs). Everyone from Trust Board members to the practitioner in clinical practice have a responsibility to ensure NatSSIPs are interpreted and feed into the creation of safe care. They should encourage practical approaches that do not hinder the care process. Moreover, they must inform and shape patient confidence in the service.
Where a Never Event occurs, remedial analysis of the local safety standards should be undertaken, while we openly and honestly communicate with the patient about what happened. Duty of Candour is essential in building a safety culture as it brings our responsibilities to the fore in every patient engagement. Heightened awareness of responsibilities in local and national standards affords practitioners the opportunity to review contributory risk factors that can arise from inadequate policies and procedures, workspace and environment design, and organisational culture.
Leadership skills can help to improve patient care
Leadership is therefore crucial in the compliance to standards and procedure recommendations. Without clear communication via the interprofessional team and poor leadership there is an increased potential for harm to occur. Improving the understanding of safety standards, procedures and their application to care via simulated events and discursive workshop are beneficial in reducing Never Events. Learning in this manner supports sharing of knowledge across the clinical team and consideration of the change in health care demographics.
Safer surgery is essential. We must exercise effective leadership to promote patient wellbeing, and optimize the utilisation of theatre resources. In many ways, leadership is about creating a sense of inclusion and direction on how we can best care for patients. Heightened emotional intelligence among perioperative practitioners provides a host for owning our emotions at work. This insightfulness encourages us to be self-aware and self-manage our reactions to situations during the operating session. It aids us to cope with pressure, become resilient and remain dependable for our patients. For practitioners, it also sharpens their ability to question practice, ensuring our duty of care is being upheld against defined evidence-based standards.
To care, or to be cared for, is, in fact, a trusting relationship. Patients trust practitioners to look after them and to bring no harm to them. Trust is more than reliability; it’s about people being good, honest and skilful in the work role to look after the vulnerable patient. A Duty of Care is paramount in our practice and requires courage and commitment to what we do and the way we do it. Taking the correct action for the benefit of others is a vital beneficent act. But, where errors or Never Events occur, we have to be accountable and learn from those mistakes.
There is no doubt that pioneers such as Aneurin Bevin, Mary Seacole, Daisy Ayres, Joseph Lister, John Snow have influenced today’s health care. The University of Derby’s Perioperative Care Conference focuses on supporting the continued development of perioperative practitioners to help reduce potential errors, learning from advancements in technology, and surgical techniques to delivery of effective safe care. For more information about the conference and to register, visit our website using the link below.
- Alcorn, S. and Foo, I (2017) Perioperative management of patients with dementia. British Medical Journal. 17 (3) 94-98
- NHS England (2015) National Safety Standards for Invasive Procedures (NatSSIPs). NHS England.
- NHS Improvements (2017) Provisional publication of Never Events reported as occurring between 1 April 2016 and 31 January 2017. London: NHS Improvement.
- World Health Organization (2008) Surgical Safety Checklist. [Available online]. http://www.who.int/patientsafety/safesurgery/ss_checklist/en/ [Accessed 19th March 2018].