NHS England’s patient safety director has said there is no excuse for surgical never events after it was revealed 85 trusts reported incidents such as wrong site surgery in the first half of 2013-14.
The national body yesterday published organisation-level data on never events for the first time. In total, 152 never events were reported through the strategic executive investigation system between April and September, by 102 NHS providers and eight independent sector hospitals.
Of these, 86 per cent were either wrong site surgery, implements being retained in the body after surgery, or the wrong implant or prosthesis being used. Newcastle upon Tyne Hospitals Foundation Trust reported the most never events, with four, all of them surgical. Six trusts reported three surgical never events during the six month period.
The figures are consistent with previous years. In 2012-13, 290 never events were reported to STEIS, of which 87 per cent were surgical.
National patient safety director Mike Durkin told HSJ it was “very disappointing” that there was still a significant number of surgical never events.
“I think that’s completely unacceptable, particularly as there is guidance in place to prevent them,” he said. “There isn’t really an excuse.”
The most common type of wrong implant prosthesis was the inserting of an incorrect lens during ophthalmic surgery.
Dr Durkin acknowledged the rate of surgical never events is one in every 20,000 procedures, however he said it was “difficult to understand” why people were not following the World Health Organization’s surgical safety checklist, which is widely accepted as being best practice.
He said root cause analysis of surgical never events often found that although checklist “boxes had been ticked”, surgical teams had not actually followed all the stages it described.
“That calls into play the human factors of how mistakes are made – the pressure which some systems are working under which creates an environment that doesn’t allow reflective time,” he added.
He said trusts needed to ensure time was being allowed for briefings before and after a theatre list. Commissioners should also play a part by making sure they “really understand” why incidents occurred and whether there was anything they could do to ensure they were not repeated.
“This is a leadership challenge for the operating theatre as much as a technical challenge,” he said.
Dr Durkin said the Safe Surgery Taskforce he set up to look into this issue, which is due to report in January, would recommend a more systematic approach, with standardised procedures and standardised education and training.
However, Dr Durkin said the “key issue” was the ability of the theatre team to “accept that at every stage someone may say something that’s valuable to the rest of the team”.