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New national safety standards to tackle surgery 'never events'

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A new set of national standards have been published in a bid to reduce the number of patient safety incidents related to invasive procedures that could lead to so-called “never events”.

The National Safety Standards for Invasive Procedures, created in conjunction with NHS England, have been produced after the introduction of a mandatory checklist five years ago failed to significantly reduce the prevalence of “never events” during surgery in England.

“Never events” are a type of serious incident that are defined, among other criteria, as being wholly preventable and as having the potential to cause serious patient harm or death.

Invasive procedures currently account for about 85% of all recorded “never events” in England.

“There are still unacceptable levels of harm caused by never events and serious incidents… it remains vital that all health professionals remain vigilant in working to these standards”

Mike Durkin

The 13 new standards build on the World Health Organization’s Surgical Safety Checklist – which became mandatory in 2010 – and have been devised in response to a recommendation from NHS England’s Surgical Never Events Taskforce Report, published last year.

They require all NHS organisations to create standardised documentation for patients undergoing invasive procedures that “promotes the sharing of patient information between individuals and teams at points of handover, and forms a record for future reference”.

Invasive procedure documentation should also allow members of the team present at each stage in the patient pathway to be identified, and a record should be kept of the performance of the key safety checks in the patient pathway, state the standards.

They also set out the principle that the “safe care of patients undergoing invasive procedures depends upon having the correct numbers of appropriately trained, skilled and experienced staff members who work together effectively in a team”.

When different members of the workforce have clinical responsibilities outside of the procedural area, “the potential for competing and irreconcilable clinical demands must be addressed,” notes the document.

“This is most commonly an issue outside of normal working hours, and examples include theatre staff allocated to the designated emergency theatres also covering the obstetric theatre or cardiac arrest teams, or medical staff covering both theatres and emergency departments or wards,” it said.

“Safe care of patients undergoing invasive procedures depends upon having the correct numbers of appropriately trained, skilled and experienced staff”

National Safety Standards for Invasive Procedures

Those behind the standards also noted that for wrong site procedures, nurses admitting the patient to the procedural area or the patient themselves are the people most likely to identify an error, and highlighted the importance of communication.

Dr Mike Durkin, NHS England director of patient safety, said: “There are still unacceptable levels of harm caused by never events and serious incidents and so it remains vital that all health professionals remain vigilant in working to these standards so that we can continue to reduce the harm they cause to patients.”

He noted this was the first time national safety standards had been set and endorsed by all relevant professional bodies, including the Royal College of Nursing, the Care Quality Commission, the Nursing and Midwifery Council, the General Medical Council and Health Education England.

The standards have been created with the new duty of candour law in mind, which requires organisations to apologise to patients and families when something has gone wrong with their care.

While this legal duty does not apply to individual clinicians, they will still be expected to cooperate with their organisation’s policies and to abide by their regulator’s requirement to be open, noted the document.

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