Safety first

The World Health Organization (WHO) Safe Surgery Saves Lives initiative began in 2008 and has seen more than 200 national and international medical societies and ministries of health working together to reduce avoidable deaths and complications in surgical care. The National Patient Safety Agency (NPSA) supports the WHO initiative and is working with key organisations representing perioperative professionals – including the Association for Perioperative Practice (AfPP) – to take forward work in the UK.
    
The scale of the issue is dramatic. 301,368 incidents were reported in England between 1 April and 30 June 2009; representing an increase of 44,626 incidents compared to the previous quarter (256,742 incidents in January to March 2009). 22,180 incidents were reported in Wales between 1 April and 30 June 2009, this is an increase of 8,527 incidents compared to the previous quarter. These incidents vary hugely from incorrect treatment or procedure to misplaced patient notes. Not all of these incidents are serious but some have led to patient harm or death and many could have been prevented.
    
Diane Gilmour, president of the Association for Perioperative Practice, commented: “We want to make surgical safety everyone’s highest priority and include practical suggestions to achieve just that. Our membership represents all those working in operating theatres and so we particularly welcome the emphasis on encouraging a culture of safety embracing the whole surgical team.”
    
AfPP is strongly supporting the Patient Safety First campaign. This campaign is led by NHS clinicians to help NHS clinicians. Its cause is to ‘make the safety of patients everyone’s highest priority’ aiming for ‘no avoidable death and no avoidable harm’. The campaign has identified a series of ‘interventions’ in healthcare that can improve patient safety.

These areas for improvement are:

• Leadership for safety
• Reducing harm from deterioration
• Reducing harm in critical care 
• Reducing harm in perioperative care 
• Reducing harm from high-risk medicines

The campaign encourages trusts to sign up to its aims by introducing at least two of the above interventions.

Surgical Safety Checklist
The perioperative ‘intervention’ concentrates on two areas – reducing surgical site infection and the introduction of the WHO Surgical Safety Checklist. The checklist has three main elements – sign in, time out and sign out.
    
Each of these elements contains a simple set of questions for the whole perioperative team that ensures that the whole team knows one another, the patient and the procedure that is to be undertaken. The checklist ensures that any complications which might occur are anticipated at the outset. During the sign in part of the checklist the identity of the patient is confirmed as well as the procedure to be undertaken, the body area where the procedure is to be applied and checking that the patient’s consent has been obtained. Other checks are made on areas that might cause a problem such as the patient having airway problems and the potential for blood loss.
    
Before any skin incision, the time out section of the checklist is used. All the team introduce one another by name and role. The surgeon, the anaesthesia team and the nursing team all report on any critical events they anticipate during the procedure.
    
Finally, before the patient leaves the operating theatre the checklist ensures that all the instruments and swabs have been counted out to ensure they tally with those that were counted in. This reduces the chances of equipment being left in the patient. A review is undertaken of the equipment and the procedure to ensure that any concerns are logged and action taken.
    
Through the reliable implementation of the Surgical Safety Checklist significant improvements in outcomes for patients as well as a better and more efficient working environment for staff can be realised.
    
All over the world, including in the UK, health care workers are proving that patient safety can be greatly improved and many complications or harm events that were previously considered unavoidable actually are avoidable. They are in fact, redefining what is acceptable in terms of patient safety. The checklist was designed for international use so there may be some items that are already accepted or essential practice in the UK. Therefore local organisations are adapting the checklist to their local context.
    
It is recognised that there may be some rare emergency situations where stopping to use the checklist may not be appropriate. The National Patient Safety Agency (NPSA) has mandated all health trusts in England and Wales to adopt use of the checklist by February 2010.

5 good reasons why practitioners should use the Safer Surgery Checklist
1. The WHO Checklist is a tool to improve perioperative safety for patients. It is expected that by 1 February 2010, as a minimum, the checklist will be used for all surgical interventions in England and Wales.

2. All clinical staff groups report major improvements in the ability to perform their role, the reduction of incidents and improved team-working and communication where this has been successfully introduced.

3. Adding briefings before the list starts and de-briefings after the list ends significantly enhances the safety benefits and team performance.

4. The time invested throughout the list on briefing, the WHO checklist elements and de-briefing, should be considered an essential part of professional practice. The universal experience is that more time is saved by improved communication than is spent achieving it.

5. The checklist is not a simple tick box; it is important that teams enter  into the ‘spirit’ of the checklist as a tool to achieve cultural change.

About AfPP
The Association for Perioperative Practice (AfPP) is a registered charity working to enhance skills and knowledge within operating departments, associated areas and sterile services departments. It aims to enhance the quality of care in the NHS and the independent sector throughout the UK.

AfPP also works to encourage the exchange of professional information between members and co-operation with other professional bodies. These include the Departments of Health in the UK, the Perioperative Care Collaborative, the medical royal colleges, Chief Nursing Officers (CNOs) of all four member countries, Skills for Health and many of the British Safety Institution Committees and other groups set up to discuss specific issues related to perioperative care.