Theatre Patient Story

Review of the WHO Surgical Safety Checklist

An Associated University Hospital of Brighton and Sussex Medical School

Background

• A patient was scheduled for and had consented to ‘Total laparoscopic hysterectomy and left salpingo-oopherectomy, plus excision of endometriosis’

• A Never Event occurred: The patient also had her right ovary and fallopian tube removed during the procedure

• The event was not reported at the time. Trust managers only became aware, when the patient made a complaint a week after the procedure

• The patient expressed her concern to theatre matron and the lead investigator that this could happen again

After event review

• The after event review meeting reviewed the various steps that contributed to the incident taking place

• This included but was not limited to the use of the WHO Surgical Safety Checklist

The WHO Surgical Safety Checklist

The Safer Surgery Saves Lives initiative was launched by the World Health Organisation (WHO) in 2008 to reduce the number of surgical errors and enhance patient safety during the perioperative phase of care

The launch saw the introduction of a new surgical safety checklist for surgical teams to use in perioperative environments as part of a major drive to make surgery safer worldwide (DH, 2008)

The NPSA (2009) has adapted this checklist for use in England and Wales and it is intended for use with all patients undergoing surgical procedures.

The checklist highlights generic core safety standards that may be applied to all perioperative settings and forms part of the 5 steps to safer surgery (NPSA, 2010)

The 5 Steps to Safer Surgery

1. The pre-operative briefing

2. The sign-in phase

3. The timeout

4. The sign-out phase

5. The de-brief

The AAR found that:

the pre-operative briefing took place

the sign-in took place in the anaesthetic room; patient identity and the correct, consented procedure were accurately confirmed

the time-out step was completed

the sign-out was completed but largely unremarkable

there was no debrief at the end of the list

Concerns • Using the WHO Surgical Safety Checklist did not prevent the

occurrence of a Never Event

• Monthly audit of the WHO Checklist, suggests that 100% of patients have a completed checklist, so: • Is the checklist completed as a tick box exercise rather than a tool

to ensure safety? • The theatre team are not giving safety a high enough priority

Actions Development of the theatre vision to foster team building

Identification of team objectives to develop ownership by theatre team

Identification of team behaviours

These activities led to the identification of safety as a priority among theatre teams Dedicated governance afternoon sessions to raise awareness of:

Never events

What is an incident?

How to report incidents

Responsibility for reporting

Actions Review of WHO Surgical Safety Checklist by matron and

lead for practice development

First draft shared with theatre team leaders

Subsequent drafts shared at ‘WHO Clinics’ on governance afternoons - feedback given by theatre teams

Feedback invited via clinical leads, divisional meetings and two week pilot

The current WHO Surgical Safety Checklist

Surgical Safety Checklist

The differences

Key steps highlighted with colour

Lead for each step is described

Questions simplified

Change in staff between step 1 and 2 recorded

Specific record of incidents and responsibility for reporting

Next steps

New checklist in use in operating theatres at ESH and CSSU by 1 April 2016

two week audit of theatre team engagement with use of current and new checklist

Review brief and debrief forms

Develop specialism specific safety checklists