Darlington NEs.key

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An overview of
National Safety Standards
for Invasive Procedures
Will Harrop-Griffiths
Consultant Anaesthetist, ICHNHST, London
Chair, NatSSIPs Group, NHSI
NatS SIPs
•
Where did they come from?
•
What are they meant to do?
2008 publication
Changes in number, nature and definitions
14
•
Wholly preventable
•
National guidance provides strong
systemic barriers
•
Guidance should have been
implemented
•
Potential for serious harm or death
•
It has occurred before and has been
reported
•
Easily recognised and clearly defined
Three surgical NEs
•
Wrong implant/prosthesis
•
Retained FO post-procedure
•
Wrong site surgery (including SOME blocks)
Surgical Never Events
150
140
130
120
110
100
90
80
70
60
50
40
30
20
10
0
2009
2010
2011
2012
RFO
2013
2014
2015
Surgical Never Events
150
140
130
120
110
100
90
80
70
60
50
40
30
20
10
0
2009
2010
2011
2012
RFO
2013
2014
2015
Surgical Never Events
150
140
130
120
110
100
90
80
70
60
50
40
30
20
10
0
2009
2010
2011
RFO
2012
2013
2014
Wrong implant
2015
Surgical Never Events
150
140
130
120
110
100
90
80
70
60
50
40
30
20
10
0
2009
2010
RFO
2011
2012
Wrong implant
2013
2014
Wrong site
2015
Commonest examples of
the surgical NEs
•
Wrong implant/prosthesis
•
•
Retained FO post-procedure
•
•
Wrong lens
Vaginal swab
Wrong site surgery
•
Tooth
Solutions
•
Sack all the ophthalmologists, gynaecologists and
dentists
•
Try to do something to drive down the incidence of
Never Events
•
Which is where NatSSIPs have their origins
•
Is this really possible?
Moppett & Moppett
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All English NHS hospitals surveyed
•
Caseload and Never Events for 2011 - 2014
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742 Never Events
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Risk: 1 : 16,423 operations
•
1 NE per 12.9 operating theatres per year
•
Risk of severe harm: 1 : 238,939 operations
Moppett & Moppett
•
The statistical characteristics of NEs suggest that
they are both rare and random
•
There is no meaningful association between the
number of NEs in a hospital and other safety
indicators
•
NEs are not a useful metric to judge the quality of
care
•
Does that mean that they do not mean anything?
Prussian military
•
•
Became concerned at number of cavalry officers
killed by horse-kick
•
Carelessness of the victims?
•
Viciousness of the horses
•
Incompetence of the generals?
Collected 20 years of retrospective data
Poisson distribution
Poisson distribution
•
A formal, mathematical description of random, rare
events
•
Therefore, does any real distribution that resembles
it imply that the events are occurring purely by
chance?
•
Rather than intent or poor systems design?
Randomness and rarity
•
The two words are not synonymous
•
Just because something is rare, does not mean it is
random - it can have a clearly identifiable causes
•
Car crashes on a road may have a Poisson
distribution but that should not stop you wearing a
seatbelt
•
Never Events may not indicate systemic deficiencies
in overall hospital care but they can be prevented
Never Events
•
Prevention is possible even if eradication is not
•
Prevention is important
•
And will decrease the incidence of other adverse
events
•
Prevention will only come from learning from NEs
•
And feeding that learning back into practice
7/9/15
14/9/15
NatSSIPs
•
The product of learning
drawn from healthcare
professionals involved in
invasive procedure care
•
A system that will continue
to develop and learn from
experience
NatSSIPs
•
13 key standards at
the heart of the
document
•
5 generic standards
•
8 sequential standards
Generic Standards
1. Governance and audit
2. Documentation of invasive procedures
3. Workforce
4. Scheduling and list management
5. Handovers and information transfer
Sequential Standards
1. Procedural verification and site marking
2. Safety briefing
3. Sign in
4. Time out
5. Prosthesis verification
6. Prevention of retained foreign objects
7. Sign out
8. Debriefing
Sequential Standards
1. Procedural verification and site marking
2. Safety briefing
3. Sign in
4. Time out
5. Prosthesis verification
6. Prevention of retained foreign objects
7. Sign out
8. Debriefing
Not just a long list of new standards
Not just a new set of boxes to tick
•
Clear focus on teamwork and human
factors
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Sets multidisciplinary training as a
core activity for procedural teams
•
The basis for the creation of Local
Safety Standards for Invasive
Procedures = LocSSIPs
LocSSIPs
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Local standards developed by those delivering
invasive procedure care
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Patient input where practicable
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Contain core elements of NatSSIPs as a minimum
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Adapted for local use to maximise patient safety
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Continuous review and development
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Continued learning from incidents
What will success look like?
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More teamwork and human factor training
•
Better communication and teamwork
•
Shared learning from SIs and NEs
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A decrease in near misses and other patient safety
incidents
•
Just maybe… in the future… a decrease in (not an
abolition of) Never Events
The End
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