• Care Quality Commission considers universal standard operating procedures for clinicians
  • It warns that clinical autonomy is currently being prioritised at the expense of patient safety
  • Concerns over consistently high numbers of “never events”

Universal standard operating procedures for clinicians to follow could be introduced across the NHS to try and cut the number of never event mistakes, HSJ has learned.

The Care Quality Commission has revealed its early thinking as part of an inquiry into why the number of “never events” in the health service, such as operating on the wrong part of the body, are not falling.

While it stressed its investigation was ongoing, the quality regulator said: “It may now be time to create standardised operating protocols for certain tasks, as we see used effectively in other safety critical industries.”

It also warned that clinical autonomy is currently being prioritised at the expense of patient safety.

Last year, former health and social care secretary Jeremy Hunt asked the CQC to review the issues that contributed to never events happening when he became concerned the numbers were too high.

Although rare, never events – which are the most serious type of preventable errors – continue to occur with 469 such incidents reported between April 2017 and March 2018.

As part of the investigation the CQC is visiting NHS trusts, taking evidence from academics and experts from other industries.

A CQC presentation, seen by HSJ, said early themes included a failure to reflect the high risk nature of healthcare in the everyday culture and practice of the NHS.

It said: “Professional autonomy is important and necessary to enable clinicians to deal with complexities, but this is all too often prioritised at the expense of proven safety protocols and policies. It is common to find workarounds even where protocols have been put in place.

“It may now be time to create standardised operating protocols for certain tasks, as we see used effectively in other safety critical industries.”

It added that safe care can “come second” to providing timely care given the pressures on the NHS and warned training for all staff may need to change to ensure safety is fully embedded.

“It may be time that we recognize the fallibility of practice, understand the tension between the concept of never events vs human factors and work to manage risks proactively rather than purely reactively,” the CQC said.

In 2008, the World Health Organisation highlighted the benefits of SOPs as “a daily feature of many high-risk industries” but added their adoption in healthcare was slow because of resistance by clinicians despite evidence that they do work.

WHO said SOPs were “not designed to turn healthcare into a production line. Instead, SOPs provide a stable basis, particularly suited to high-risk areas and practices, on which clinical excellence can flourish.”

The largest number of never events often occur in surgery. Professor Timothy Rockall, chair of the Royal College of Surgeon’s invited review mechanism, told HSJ: “Many aspects of surgery are already standardised to help protect patients. The WHO surgical safety checklist is one example of this.

“The CQC has not yet published any detailed ideas so we do not know if or how standardised operating protocols would be put in place. However, we would not necessarily expect the actual surgery to be subject to protocol. The very nature of surgery means trained surgeons require some autonomy when operating.

“It is more likely that some activities around the whole surgical pathway could be standardised, for example patient identification, consent, surgical site confirmation, implant identification, imaging and record keeping. Where implants are used then evidenced based use of appropriate, safe and cost effective implants such as types of mesh or types of joint replacement could be more standardised than is currently the case and would be in line with the ‘Getting it Right First Time’ (GIRFT) programme.”

As part of the work, the CQC has visited 18 NHS trusts, eight universities and involved patient safety experts from 10 countries including Denmark, New Zealand, Latvia, Turkey, and Estonia.

Professor Ted Baker, chief inspector of hospitals, told HSJ: “Real improvements to patient safety will only happen when transparency is prioritised and learning is shared.

“Working with NHS Improvement, we are reviewing what NHS trusts have done to establish robust safety systems, and to learn from mistakes when they do occur, as well as what the barriers might be to achieving this.

“We have identified a number of emerging themes that we will be looking to further explore over the next few months and we will report on our findings later in the year.”

The final report is expected in October 2018.