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MAR 21/2014

Preventing never events in the UK

NHS surgeons could find themselves increasingly in demand over the coming years as part of the government's ongoing efforts to improve the safety, reliability and transparency of NHS surgical care.

In recent months, the Department of Health has made a number of key commitments to improving the standard of care received by patients across Britain, in the wake of the Francis Inquiry into high-profile failings at the Mid-Staffordshire NHS Foundation Trust.

Last month, NHS England issued a series of new recommendations in response to a report on one of its key areas of focus for care quality - the improved detection and elimination of so-called surgical "never events".

This is a term given to a category of particularly serious surgical accidents and errors that technically should never occur, due to the existence of sufficient guidance to prevent them. Examples of never events include surgery on the wrong part of the body, the use of an incorrect implant or prosthesis, or foreign objects being mistakenly left inside a patient after surgery.

A Surgical Never Events Taskforce was commissioned by NHS England last year to examine why currently available preventative tools and guidance are not succeeding in completely eliminating these never events. Their report revealed that 255 incidents were reported in 2012/13, caused by a combination of factors.

These included high volumes of care, human error, miscommunication, poor team coordination, unsafe behaviours, inefficient use of technology, inadequate staffing levels and insufficient provision of training.

Although these incidents remain rare - the 255 incidents in 2012/13 came in the context of 4.6 million hospital admissions leading to surgical care annually in England - by definition, even one never event is unacceptable.

Dr Mike Durkin, director of patient safety at NHS England, said: "Patient safety has come a very long way in the past few years and there has been a real revolution in how we monitor, manage and learn from incidents and build systems to minimise the risks of surgery.

"But every single never event is one too many. Many cause severe, life-changing harm and all of them damage confidence and trust in healthcare services."

As such, the taskforce has called for greater consistency between hospitals in all parts of the country, focusing on three core themes - standardisation, education and harmonisation.

This will involve the development of high-level national standards of operating department practice to support all providers of NHS-funded care, allowing them to develop and maintain their own more detailed local procedures. Meanwhile, all staff working in operating theatres will be provided with consistent training and education, backed up by a range of multimedia tools to aid the implementation of standards and support for surgical safety training, including human factors.

Finally, efforts will be made to ensure uniformity in the reporting and publishing of data on serious incidents, as well as in the dissemination of learning arising from never events. Combined with the imminent introduction of new laws to ensure all NHS trusts regularly publish data on safe staffing levels, these measures will help to tackle the problem at the root.

Clare Marx, council member and patient safety lead at the Royal College of Surgeons, said: "We must be able to speak to patients in a compassionate, caring and honest way and create a culture where all staff feel they are able to learn from incidents that lead to failures in care."

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