They should never happen...preventing never events

They should never happen, but tragically for patients, sometimes they do. A never event is a terrible misnomer for serious untoward events that, despite the introduction of the WHO safeguards, are occurring over 200 times a year in the UK. Wrong-site surgery and retained foreign object should never happen if all the safety checks are applied, but human factors can confound the operating team so that in about 1 in 30,000 operations, an error is made.

So why do operating teams make these errors? When we discuss these events one explanation surgeons often give is the mounting pressure in the NHS to deliver an efficient service. Surgeons are all under pressure as never before. We often find ourselves re-arranging patients on our operating list as we go along because a patient has no bed, or hasn’t fasted long enough, or their transport is delayed. It is not uncommon for unscheduled patients admitted as an emergency to be added to an operating list at the last minute, creating further pressure on the team to finish on time. These unexpected changes in patient lists make it more difficult for the team to remain organized, potentially leading to errors in the safety checks.

Generic waiting lists - where a patient has seen one specialist in the out-patients, but is having their operation performed by the surgeon with the first availability, in order to reduce their waiting time - means that the first time the surgeon meets a patient may be a few minutes before the operating list is due to start. Inevitably this will mean that the surgeon is less familiar with the patient when they arrive in the operating theatre. All this in the context of incessant pressure to deliver the service within the targets required makes it feel like more and more for less and less. Something has to give - and it is up to surgeons to ensure that it is not patient safety. If it is, the patient will pay the price, and it will be the surgeon, not the system, who will be held responsible and could find themselves subject to criminal prosecution.

And it’s not just in the operating theatre that we can make these errors. I was drawn into an error by a patient who lived at the same address as his son, who had the same name and he hadn’t noticed that the date of birth on his appointment letter was for his son, not for him. As a result, he attended outpatients expecting to see an orthopaedic surgeon about his knee but didn’t complain when I enquired about his haemorrhoidal symptoms and then offered to band his haemorrhoids as he was having such trouble with them. In fact, he had had trouble with his piles for years and was very grateful, if a little surprised, to have them treated. Times have changed since then and nowadays I would have checked his date of birth and realized that he was in his sixties and the patient I was expecting was in his forties.

From the surgeon’s perspective, saying “I wouldn’t have done that,” is not the best way of contemplating why never events occur. Interruptions and distractions can lead to errors and cannot be predicted. So how we can help protect patients and prevent never events from happening? Team training in communication and awareness of human factors is essential and should be available to all surgical teams. As individuals we need to learn to say ‘stop’ if we believe that something is not correct; and ‘no’ when we feel we are under pressure to do something without adequate time to perform the safety checks. It is very important that we know when to stop operating and do not take on more than we can manage.

It is also important that we, the surgeons, make sure we know our team before we start an operating list. We might find ourselves working with unfamiliar staff or there may be staff changes during the list. How the surgical team relates to each other and to the members of the nursing and anaesthetic teams is very important. Team training has been shown to be effective in reducing the number of errors made. Theatre staff are not going to stop us making an error if they are afraid to speak up. So many times when never events have been investigated, there was somebody present who thought that something was wrong but assumed that it was their mistake not everybody else’s. We need these people to feel they are an important part of the team and speak up if they are worried. Making time for the team brief at the start of a list helps break down perceived barriers.

Of course, we need time to do this. We need to take time to surround ourselves with a team of professionals who all know what we are doing and why; time to check that this is the patient that we were expecting and that this is the operation that they need; time to check the instruments and swabs again and again; time to ensure that the prosthesis is the one we asked for and that we have asked for the one that is correct. But more than this, we need to recognize the importance of being part of a team. This will prevent us making preventable mistakes that should never happen and which are devastating for patients and their surgeons, even if no harm has been done.

Mr Andrew Miles is a Consultant Colorectal Surgeon and a Director of Professional Affairs at the Royal College of Surgeons. He runs a regular discussion forum at RCS for clinicians and hospital managers to share best practice in the avoidance of never events.

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Notes 

• The Royal College of Surgeons has produced a guide on The High Performing Surgical Team
• ‘Good Surgical Practice’ also sets out our standards for all surgeons and their practice. It can be read here: GSP