Finding the Positives from Never Events

Finding the Positives from Never Events Judith Connor Assistant Director Quality Assurance South Tees Hospitals NHS FT Delcy Wells Patient Safety Lead County Durham & Darlington NHS FT

Never Events: A potted history • USA experience • 2001 list of 28 Source: Sentinel Event Statistics. September 30, 2009. The Joint Commission Web site.

Source: Adverse Health Events in Minnesota. Fifth Annual Public Report. St. Paul, MN: Minnesota Department of Health; January 2009.

The National Patient Safety Agency produced a list of 8 core never events in March 2009: wrong site surgery; retained instrument post-operation; wrong route administration of chemotherapy; misplaced naso or orogastric tube not detected prior to use; inpatient suicide using non-collapsible rails; escape from within the secure perimeter of medium or high security mental health services by patients who are transferred prisoners; in-hospital maternal death from post-partum haemorrhage after elective caesarean section; Intravenous administration of mis-selected concentrated potassium chloride. Guidance on implementing the never events framework. Health Service Journal. 15 May 2009

Context 4.6 million hospital admissions that lead to surgical care every year in England 500,000 non-Caesarianbirths also tens of thousands of other interventional procedures like internal radiology and cardiology catheter procedures that are also classified as “surgical” in terms of never events. incidence rate is less than 0.005% or 1 never event in every 20,000 procedures.

Never Events in England List increased to 25 in 2013 Surgical Never events task force Feb 2014 New Never Events Policy and Framework published March 27th 2015 List decreased to 11 categories.

Never Events 1 April 2012 to 31 January 2013 by type of incident

Never Events 1 April 2013 to 31 March 2014 by type of incident

Never Events 1 April 2014 to 31 January 2015 by type of incident

Number of never events relating to surgical error 12/13 255 13/14 286 14/15 216 What are we learning?

Insertion of wrong size intraocular lens Never Event Category: Wrong Implant Previous Medical History The patient has type II diabetes resulting in co-existing diabetic retinopathy. Previous left cataract surgery, rationale for surgery relates to intermittent pain and blurs, poor vision - right eye. Reason for admission Right cataract surgery with intraocular lens implant. What happened The wrong size diopter lens was inserted into the right eye. This was recognised before the patient left theatre and the lens was removed. No other lens was inserted due to the cornea being cloudy.

Impact on the individual The patient was temporarily left with poor vision due to no alternative lens inserted which would impact on their day to day activities. Patient requires further surgery to right eye to insert correct size diopter lens. Prognosis It is anticipated following insertion of correct lens that the prognosis would be as previously expected.

Action Taken Immediately Following Incident • Operating consultant sought further advice from a consultant colleague who attended to assist with removal of the lens. The lens was removed from the patient’s right eye. The correct lens was not inserted because the cornea was cloudy. The plan of action was to review the patient in outpatients and arrange for further surgery when appropriate. • Proposed actions included: • Ophthalmic Surgical Safety Checklist – draft amendments made for approval and subsequent implementation on both sites. • Standard Operating Procedure has been produced in draft format for approval and subsequent implementation on both sites.

Root causes: • Misinterpretation of the surgeon’s handwriting in the patient’s notes by the nursing staff • Failure to cross check IOL power gleaned from notes with information on the theatre list. • Lack of pre-operative briefing which inhibited an opportunity to confirm the diopter size. • lack of written IOL power and style on whiteboard

Lessons learned • The surgeon delegated the identification of the power of the IOL in the case records to a circulating nurse • Handwritten IOL power can be mis-interpreted especially if read by a third party • The IOL power and style was not transferred to the theatre whiteboard • Theatre nursing staff did not cross-check the IOL power with the printed theatre list

Because it was not written on the theatre whiteboard, there was no immediate way to check the IOL power immediately prior to insertion. • There was no pre-operative briefing prior to this procedure. • Staff did not challenge practice which they felt was not conducive to their working environment/practice (dimming of lights throughout the procedure, checking patient notes for diopter lens size).

Was this a system error or human error?

Recommendations • A dedicated cataract surgery safer surgery checklist • A Standard Operating Procedure for IOL insertion • Equipment requirements to be clarified and sourced for unexpectedly complex surgery. • Expansion of the core team having the required skills to assist with ophthalmic surgery. • Ensure pre-operative briefings are undertaking for patients that may not have been currently admitted just prior to the commencement of a list.

Solutions: Human vs System Will they address the issues?

NEVEREVENTS (as stated there were 25 now 11) The Clinical & Quality Strategy

Never Events The Trust had 1 never event for 2013/14 (guidewire) reported on STEIS 22/11/2013 and then 3 never events for 2014/15 Focus on retained foreign objects post procedure as we had 2 from maternity services reported on STEIS 29/8/2014 and 5/3/2015. Our 3rd was similar to South Tees as it was an ophthalmic lens never event that was in the patient for 7 minutes before being removed as it was the wrong lens for this patient reported on STEIS 12/6/2014.

Action Plan for Ophthalmic Never Event

Maternity Never Events Incident 1 : patient had a Neville Barnes forcep delivery and then had a PPH of 1500mls. During the repair swab left in vagina. Full RCA review took place learning from this incident. PPH was managed well. There were 15 raytec swabs these were documented in the notes and on the whiteboard in the labour suite. The Midwife and Obstetrician did not do the final swab count together. It was stated to have been done by Midwife and colleague. The Obstetrician who had been covered in blood had gone to have a shower and had stated would do the swab count on their return, count was incorrect as swab was found 27/8/2014 13:15 when post natal check taking place. Background

Maternity Never Events Incident 2 : patient had a forcep delivery in theatre and sustained a 3rd degree tear during suturing stated 2 swabs placed in vagina to stop bleeding - the full RCA has not been completed as yet so full outcome cannot be shared.

Action plan from Maternity Never Event

Sign up to Safety Pledges Never Event All never events have been reviewed and extra controls put in place with the aim to prevent them taking place. Discussion at team meetings, governance meetings across the whole Trust has taken place to highlight what a never event is, how to report and consider how or what further controls need to be in place to prevent. Under collaboration this Trust stated it would share lessons learnt with regional workstreams.

From 1st April 2015 new never event list 2015/16 and new SI policy – please go to the website and read. All staff should remember there are financial penalties, damage of Trust reputation as well as the risk of harming a patient when a never event takes place.

County Durham & Darlington have agreed to take part in national research with the aim to prevent retained swabs from maternity cases. Discussed was the use of separate theatre staff to maternity as behavioural and culture different within obstetric theatres and main theatres. Again solution Human v Systems we can have all the policies and SOPs but if humans don’t follow them we could have another Never Event. Integrating Human Factors into Healthcare should be mandatory as optimising human performance by better understanding the behaviour of individuals, their interactions with each other and within the environment. In November 2013 the National Quality Board raised a concordat which aims to provide leadership and oversight for embedding Human Factors principles and practices into the healthcare system.

Finding the Positive from Never Events Improvements are being made and reductions occurring. Transparency and Duty of Candour being followed gives the general public assurance we are aiming to improve quality in the NHS all the time.

Finding the Positives from Never Events