1
Addressed to: STH
No Response Published
Link to recommendation 1
Recommendation · source text
STH should make a copy or a redacted version of this report available to NHS England so they are made aware of the recommendations specifically addressed to them. In a similar vein STH should consider publishing this report or a redacted version of it on its website so that all those who have an interest in patient safety might benefit from the insights which have been gained.
1]
Addressed to: STH
No Response Published
Link to recommendation 1]
Recommendation · source text
The guideline for surgical procedure checks should be rewritten as a policy. Consideration should be given to including sections on compliance monitoring and training. Steps should be taken to ensure that STH can demonstrate that staff understand their obligations under this policy including the escalation process to follow in the event of a missing item.
2
Addressed to: STH
No Response Published
Link to recommendation 2
Recommendation · source text
All national guidance with regard to patient safety should be incorporated into STH’s portfolio of policies. With regard to the ‘Five Steps to Safer Surgery’ process when patients need transferring to an Intensive Care Unit, the ‘debrief’ element of that process should be undertaken during wound closure432 as suggested by the National Patient Safety Agency.
2]
Addressed to: STH
No Response Published
Link to recommendation 2]
Recommendation · source text
STH should review checking processes and mandate that critical safety checks should proceed without interruption (‘sterile cockpit’)
3
Addressed to: STH
No Response Published
Link to recommendation 3
Recommendation · source text
All STH internal guidance with regard to patient safety should be incorporated into STH’s portfolio of policies.
3]
Addressed to: STH
No Response Published
Link to recommendation 3]
Recommendation · source text
STH should review alternatives for displaying used swabs which will facilitate both counting processes and estimation of blood loss. (If this process incorporates the handing off of single swabs then this would also address concerns about the occasional necessity to deviate from the practice of always handling swabs in batches of five.)
4
Addressed to: STH
No Response Published
Link to recommendation 4
Recommendation · source text
STH should make it policy that all untoward incidents are to be reported by staff to their Line Manager or Risk Lead.
4]
Addressed to: STH
No Response Published
Link to recommendation 4]
Recommendation · source text
STH should review methods for documenting the number of sharps on the whiteboard to determine if one method is safer and to ensure the preferred method is consistently utilised across the organisation.
5
Addressed to: STH
No Response Published
Link to recommendation 5
Recommendation · source text
STH should make it policy that surgeons must not use any accountable item of medical equipment if it is not passed to them by the Scrub Nurse except where a failure to do so it would compromise the life of a patient.
5]
No Response Published
Link to recommendation 5]
Recommendation · source text
The policy for surgical procedure checks should contain explicit guidance about which items should be retained and counted and how these items should be documented on the whiteboard.
6
Addressed to: STH
No Response Published
Link to recommendation 6
Recommendation · source text
STH should make it policy that the senior surgeon or doctor undertaking a surgical/invasive procedure is accountable for the ‘Five Steps to Safer Surgery’ process being completed in its entirety.
6]
Addressed to: STH
No Response Published
Link to recommendation 6]
Recommendation · source text
STH should undertake a risk assessment for the use of cotton wool balls in theatre and if alternatives are deemed unsuitable determine if a more dependable means of tracking them is available.
7
Addressed to: STH
No Response Published
Link to recommendation 7
Recommendation · source text
STH should enter discussions with the AfPP to explore how their published recommendations in the area of Swab Checks might be incorporated in to STH policy without AfPP’s copyright being breached.
7]
Addressed to: STH
No Response Published
Link to recommendation 7]
Recommendation · source text
STH should develop a safe surgery policy describing what standards of care every patient should receive during a theatre episode. The policy should include a compliance monitoring section as well as detailing training requirements.
8
Addressed to: STH
No Response Published
Link to recommendation 8
Recommendation · source text
STH should make arrangement so as to ensure that all Consultant Surgeons and surgical trainees receive training on the ‘Five Steps to Safer Surgery’ and ‘Swab Checks’ and documented on their training records.
8]
No Response Published
Link to recommendation 8]
Recommendation · source text
The safe surgery checklist should be redesigned.
9
Addressed to: STH
No Response Published
Link to recommendation 9
Recommendation · source text
STH should make arrangement so as to ensure that all Anaesthetists receive training in Swab Checks.
9]
No Response Published
Link to recommendation 9]
Recommendation · source text
If ‘anaesthetic machine check’ is moved to team briefing the anaesthetic machine check logbooks become obsolete and should be removed.
10
Addressed to: STH
No Response Published
Link to recommendation 10
Recommendation · source text
STH should make arrangement so as to ensure that all Anaesthetists who have been trained on the ‘Five Steps to Safer Surgery’ process are accurately recorded.
10]
Addressed to: STH
No Response Published
Link to recommendation 10]
Recommendation · source text
STH should trial Time Out in a three way scripted discussion format.
11
Addressed to: STH
No Response Published
Link to recommendation 11
Recommendation · source text
STH should explore undertaking whole team training for surgical and operating theatre teams as, for example, that developed by the Association of Perioperative Practioners.
11]
Addressed to: STH
No Response Published
Link to recommendation 11]
Recommendation · source text
STH should include a theatre checklist in the patient’s notes/theatre pathway documentation.
12
Addressed to: STH
No Response Published
Link to recommendation 12
Recommendation · source text
STH should consult with other NHS Trusts to ascertain the amount of time they allocate to Morbidity and Mortality meetings. Senior management should then ensure that the medical staff at STH are provided with at least the same opportunity to learn from their colleagues.
12]
No Response Published
Link to recommendation 12]
Recommendation · source text
The membership of the safe surgery steering group should be reviewed to increase representation from other theatre suites.
13
Addressed to: STH
No Response Published
Link to recommendation 13
Recommendation · source text
All Investigating Officers at STH should receive additional training on human factors and how investigations in to serious untoward incidents ought to be undertaken.
13]
No Response Published
Link to recommendation 13]
Recommendation · source text
Identical audit processes for the safe surgery checks should be in place in all theatre suites.
14
No Response Published
Link to recommendation 14
Recommendation · source text
The circumstances surrounding Never Event’ 10: surgery440 should be re-examined and the reason(s) for the failure of the surgical team to follow STH and NPSA guidance regard the insertion and removal of throat packs established.
14]
No Response Published
Link to recommendation 14]
Recommendation · source text
A policy for surgical marking should be written with recommendations for training and auditing of compliance. This policy could be incorporated into an overarching ‘safe surgery policy.’
15
No Response Published
Link to recommendation 15
Recommendation · source text
The Surgeon who found the retained throat pack in ‘Never Event’ 10: surgery442 should be interviewed. The reason(s) why the operating theatre staff were not informed that a ‘Never Event’ had occurred and precisely what the Surgeon did with the retained throat pack once it had been found should be established.
15]
No Response Published
Link to recommendation 15]
Recommendation · source text
Specimen handling processes should be reviewed to improve reliability and consistency. The process should enable staff to demonstrate the presence of the correct number and type of specimen during Sign Out.
16
Addressed to: STH
No Response Published
Link to recommendation 16
Recommendation · source text
STH should verify that the feedback system which provides information to staff who have reported untoward incidents is working as envisaged.
16]
Addressed to: STH
No Response Published
Link to recommendation 16]
Recommendation · source text
STH review how details from SIRI investigations and reported incidents is communicated back to both the theatre team and the wider organisation.
17
Addressed to: STH
No Response Published
Link to recommendation 17
Recommendation · source text
STH should investigate the possibility of introducing new technology such as bar coding or radio-frequency identification to reduce the risks of patients inadvertently retaining foreign objects following surgical/invasive procedures.
17]
Addressed to: STH
No Response Published
Link to recommendation 17]
Recommendation · source text
STH consider the introduction of a theatre ‘code of conduct’ which emphasizes the important of critical safety checks and includes the requirement for a ‘sterile cockpit’ during these checks.
18
Addressed to: STH
No Response Published
Link to recommendation 18
Recommendation · source text
STH should install ORMIS in the Cardiac Operating Theatres at the Northern Hospital site as soon as practicable.
19
Addressed to: STH
No Response Published
Link to recommendation 19
Recommendation · source text
STH should ensure that the air exchange system operating in the rooms previously used to prepare surgical instruments for cardiac operations at the Northern Hospital site are, as soon as reasonably practicable, repaired and/or upgraded so as to meet statutory air quality standards.
20
No Response Published
Link to recommendation 20
Recommendation · source text
Arrangements should be made for the introduction of formal audits and spot checks for the departments of Radiology and Endoscopy.
21
Addressed to: The department of Endoscopy
No Response Published
Link to recommendation 21
Recommendation · source text
The department of Endoscopy should develop a safety checklist which incorporates the principles of the WHO Safer Surgery Checklist.
22
No Response Published
Link to recommendation 22
Recommendation · source text
The guideline for the removal of a Rusch Balloon should include a requirement that a physical examination be undertaken to ascertain whether a patient has a vaginal pack which also needs to be removed.
23
Addressed to: STH
No Response Published
Link to recommendation 23
Recommendation · source text
STH should approach the Commissioners of services with a view to implementing the ‘Acommissioning process for never events’447 as advised by the Department of Health and NHS England.
24
Addressed to: STH
No Response Published
Link to recommendation 24
Recommendation · source text
STH should make a submission to the Commissioners of services to have the nine serious untoward incidents that were misclassified as ‘Never Events - Retained instrument post-operation or Retained foreign object post-procedure’ downgraded.
25
Addressed to: STH
No Response Published
Link to recommendation 25
Recommendation · source text
STH should enter into discussions with the Commissioners of services with respect to the recovery of any financial penalties imposed on them through the provisions of the NHS Standard Contract as nine of the 11 serious untoward incidents were misclassified as ‘Never Events - Retained instrument post-operation448 or Retained foreign object post-procedure’.449
26
Addressed to: NHS England
No Response Published
Link to recommendation 26
Recommendation · source text
NHS England should as a matter of urgency publish their own or publicly endorse the AfPP’s guidance on the management of swabs, instruments, needles and sundry items so that the ‘Never Event -‘Retained foreign object post-procedure’454 will also apply where such items are inadvertently retained by patients.
27
Addressed to: NHS England
No Response Published
Link to recommendation 27
Recommendation · source text
NHS England should re-consider whether it is appropriate to use the concept of a ‘Never Event’ in relation to serious untoward incidents since the unthinkable as well as obvious events can occur.455
28
Addressed to: NHS England
No Response Published
Link to recommendation 28
Recommendation · source text
NHS England should re-consider whether it is appropriate to use the concept of a ‘Never Event’ as a category in relation to untoward incidents which are caused through an item of medical equipment being inadvertently left in the body of a patient.
29
Addressed to: The MHRA
No Response Published
Link to recommendation 29
Recommendation · source text
The MHRA should consider whether the protective caps on bulb syringes and other medical devices can be dispensed with and if not whether there is a method by which they can be tethered to a device so they cannot become detached.