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Call to use checklists to stop 'never events'

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Guidelines requiring a ‘time out’ before operations should be implemented at every hospital to prevent them facing financial penalties for wrong-site surgery, nurses have said.

Nurses made the demand following the publication of ‘never events’ – eight incidents that could lead to financial punishments for hospitals (see box).

At a hearing last week, Martin Fletcher, chief executive of the National Patient Safety Agency, told a meeting of the Commons health select committee that reporting of never events would start in 2009–2010, with financial penalties being imposed by PCTs the following year.

‘We have identified a set of events that are potentially catastrophic but highly preventable,’ he said. ‘There should be some financial consequence for unsafe care.’

The World Health Organization’s Safe Surgery Saves Lives guidelines were published in June. These require theatre nurses to state the name of the patient and details of the procedure during a pause before each operation (NT News, 22 July, p8).

Jane Reid, president of the Association of Perioperative Practice, who advised the WHO on the guidelines, said: ‘The aim is to ensure that there’s time out when the team further check that they have the right procedure and the right side.

‘WHO’s initiative has been endorsed by all the perioperative organisations and the NPSA. We have integrated it into the Safety First campaign and are working to have that integrated into all operating theatres.

‘All of these events invariably occur as a result of the failure to follow procedures.’

Claire Bradford, theatre matron at the Royal Devon and Exeter NHS Foundation Trust, which implemented the WHO checklist in June, said: ‘Theatre staff need to be confident to challenge a surgeon or anaesthetist to do time out, because everyone
is accountable.

‘It has become an integral part of our everyday practice now. We use simple questions that are on laminated A3 posters. We have got it down to one and a half minutes – it’s slick and quick.’

Dame Christine Beasley, chief nursing officer for England, told NT: ‘We will look at the data we get in the first year and see what’s the best way to penalise for never events. We don’t want to do things that may destabilise the system or have any unintended consequences.’

Never events: preventable catastrophes

  1. Wrong-site surgery

  2. Retained instrument post-operation

  3. Wrong route administration of chemotherapy

  4. Wrongly placed nasal or orogastric tube undetected before use

  5. Inpatient suicide using non-collapsible rails or while on one-to-one observation

  6. Absconding of transferred prisoners from medium or high-secure mental health services

  7. In-hospital maternal death from postpartum haemorrhage after elective Caesarean section

  8. IV administration of concentrated potassium chloride


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