The Patient Safety First Perioperative Care intervention promotes the use of a number of tools to improve safety including briefing and debriefing and the surgical safety checklist. This has had the unanimous support of the orthopaedic operating staff at Leeds Teaching Hospital NHS Trust.
According to Jan Rayner, Senior Operating Department Practitioner at the Trust, the contrast between surgical lists with and without these changes could not be more obvious. Surgical firms that have signed up to the changes recommended are less rushed, better prepared and simply more professional, she says, ‘It’s all down to how much information is communicated to the whole of the team. Instead of a surgeon rattling out instructions as he walks through the door or the operating staff having to work from a printed list that frequently lacks essential details, we are given as much information as possible in a manner that allows for advance preparation of every bit of kit and provides a foolproof system of checks and double checks’
A leading improvement expert, Orthopaedic Surgeon, Mr Mark Emerton, was already promoting the importance of making patient safety a priority prior to the launch of Patient Safety First. In fact the Trust had been using the National Patient Safety Agency’s four-point checklist since it was introduced in 2005.
However, important lessons were learnt from an incident that revealed more checks were needed, as Jan Rayner explains, ‘A patient was brought into the pre-operating room and started to receive an anaesthetic without having signed the consent form. It may not sound dangerous but it showed that a patient could be operated on without routine checks being done. We knew we needed a better system of ensuring safety in surgery.’
In April 2008, the team introduced a 'time out' session before each operation, using the WHO Safer Surgery Checklist. In order to make these changes effective, the team is now working with the Trust to develop the practice further using the Perioperative Care intervention, together with the core elements of the NPSA and WHO checklist. The new 'Surgical Communication Checklist' hinges around a ten to fifteen minute pre-op team briefing at the start of the day. This is a time when the team introduce each other, and interestingly, some of the surgeons have only got to know the names of some of the theatre staff since this briefing was introduced. ‘I naively assumed that everyone knew each other’s names and was surprised to find that some surgeons had been working for years without knowing the names of the theatre staff,’ says Jan Rayner.
Being on first name terms brings subtle but significant changes to the atmosphere in theatre. Jan Rayners view is that ‘Previously, there would only be one reason why a surgeon would know your name, usually for notably good or bad performance. Now, it’s normal and there’s a much greater sense of team effort. We feel confident to speak up if we spot anything unexpected and there’s a more dynamic approach from the whole team. We feel empowered and so performance improves. As one team member put it, positivity promotes productivity'.
Also during the briefing each operation is analysed in advance, with contributions from different team members. ‘The surgeon will highlight extra risk, for example a patient who is having a knee replacement, who has several osteophytes or a valgus deformity. The anaesthetist tells us about patients with medical problems or a potential difficulty with intubation. There is time for the rest of the team to discuss problems and prepare essential equipment,’ says Rayner.
Immediately before each operation, there’s an extra check for good measure. ‘Until we’ve had this final check, the surgeon insists that the blade doesn’t go onto the scalpel.’ A final team de-briefing at the end of the day provides an opportunity to discuss the session, evaluate the team’s practice and consider possible improvements to safety and productivity.
The enthusiasm of participants for this Patient Safety First intervention is infectious. As Rayner explains: ‘This intervention means that instead of only the surgeons knowing the plan in advance, we all know what is going to happen; we've discussed the cases and feel that each member of the team is in control and aware of their responsibilities.’