The point of surgical procedures is to save or improve the quality of our lives, but things can and do go wrong because of system or human errors. In too many cases patients are failed because of so called “never events” - serious incidents that should never happen because they’re entirely preventable.
The official list of never events in surgery includes operating on the wrong part of the body, performing the wrong procedure, leaving instruments or swabs inside the body, or having the wrong prosthesis or medical device implanted.
Never events, such as having the wrong testicle removed, can be devastating, while others prove fatal.
It’s clear that never events happen too often. A BBC investigation in May found more than 750 instances recorded in England over the past four years. These figures could be even higher, because there is still debate at local level over whether some adverse events count as never events.
The complexity of patients’ medical conditions and a surgeon’s technical competence aren’t the only determinants of how well patients fare after surgery. Root causes of surgical harm include failures in process, such as a lack of communication or poor teamwork.
Unfortunately, too many health professionals, managers and boards continue to tolerate unacceptable practises that are ultimately endured by patients.
Never say never
In 2008, the World Health Organisation launched the safe surgery checklist. Modelled on checklists used in aviation, it brought together many essential checks to be carried out before anaesthesia is administered, an incision is made and before a patient leaves the operating room.
If these essential checks are followed there’s no doubt they can reduce never events. But a checklist won’t compensate for reckless and unprofessional behaviour or significant system flaws, such as failing to carry out disciplined counting of swabs and instruments or getting a patient’s consent before their procedure.
But this hasn’t proved the case. Despite the benefits - not only to patients but also to staff, including better reported teamwork and smoother and quicker turnaround times - improvement is still hampered by some clinicians who view it negatively or report that it makes their work more difficult.
The greatest risks to patients is the tendency to view the checklist as a tick-box exercise rather than a tool to support better communication and tolerance of disruptive or abusive behaviour, conflicting work pressures and failure to learn from and act on “near miss” incidents.
For every never event, there will be a far greater number of near misses, incidents that didn’t result in injury or harm but had the potential to do so.
Doing the right thing
Staff motivation is an issue. If we accept the premise that staff have the patient’s best interests at heart and generally go to work to do a good job, then we need to know why some lack motivation and/or are purposefully obstructive - especially given the levels of trainee rotation and staff turnover in operating theatres.
If, for example, a surgeon is asked to attend briefings and repeatedly fails to show up, are they deliberately obstructive or are there other important commitments such as ensuring other patients are discharged on time? Or has priority for patient care been eroded by cost and staffing constraints that mean minimum, let alone optimum, standards of care are difficult and staff have lost their focus?
Understanding why negative behaviour pervades the NHS is explained in part because humans are by their nature incapable of consistently following rules. And because, in the absence of safe clinical systems, we routinely deviate from standard procedures to creatively manage changing situations. But patients shouldn’t be subject to a lottery.
Why individual staff fail to do what is asked of them is a perennial challenge, not only for the NHS but virtually every industry. While we can look at how risk assessments, individual judgement, organisational culture and transparency are intertwined, failing to engage staff and instill a culture of safety lies at the doors of boards, managers and clinical leaders.
Of concern, harassment and bullying still prevail in many organisations, at both system and individual level, which stops staff “doing the right thing”.
There are still also too many assumptions in play; that staff have been told what or how they should do something and that they understand what is required of them. But this isn’t necessarily the case. It’s ironic because checklists are designed to improve communication.
Paying the price
A great many staff associated with a never event are psychologically damaged and unable to come to terms that an omission on their or their team’s part resulted in harm to a patient. Too many staff never return to work because of the emotional impact and stress.
Corporate risk needs to be articulated because it can usually get most staff on side. While patient safety comes first, mistakes are also financially costly. Hospitals are penalised for never events. The NHS paid a record £1.2bn following legal claims between 2011 and 2012 and while this wasn’t exclusively for never events, it’s clear the NHS can ill afford it.
Though never events continue to happen, we can never be complacent. We need to embrace safety science at scale and equip staff to understand how human factors affect safety. Patients put their trust and health into clinical hands and judgement so we must strive to make surgery safer. Desire for clinical excellence must always be far greater than our fear of failure or tolerance of mediocrity.
The never list in full
1. Wrong site surgery
2. Wrong implant/prosthesis
3. Retained foreign object post operation
4. Wrongly prepared high-risk injectable medication
5. Maladministration of potassium containing solutions
6. Wrong route administration of chemotherapy
7. Wrong route administration of oral/enteral treatment
8. Intravenous administration of epidural medication
9. Maladministration of Insulin
10. Overdose of Midazolam during conscious sedation
11. Opioid overdose of an opioid-naïve patient
12. Inappropriate administration of daily oral Methotrexate
13. Suicide using collapsible rails
14. Escape of a transferred prisoner
15. Falls from unrestricted windows
16. Entrapment in bedrails
17. Transfusion of ABO-incompatible blood components
18. Transplantation of ABO or HLAincompatible organs
19. Misplaced naso- or oro-gastric tubes
20. Wrong gas administered
21. Failure to monitor and respond to oxygen saturation
22. Air embolism
23. Misidentification of patients
24. Severe scalding of patients
25. Maternal death due to post-partum haemorrhage after elective caesarean section