Never Events
Management Scenarios
Scenario
You are the vascular surgeon CT2 and have been asked perform a 2nd ray amputation of the left foot. The patient is anaesthetised and the WHO surgical checklist has been performed, however, you notice that the right side 2nd toe has been marked and the patient has been consented for the wrong side.
How would you approach this situation?
This scenario revolves around a potential never event with serious potential patient harm. Utilise the SPIES mnemonic to address and manage the issues raised:
Seek Information
Review the Consent Form: Verify the details on the consent form, including the procedure and the specified side.
Check Medical Records: Confirm the intended procedure and correct side by reviewing the patient's medical records, clinical notes, and imaging studies if available.
Patient Safety
Stop the Procedure: Immediately halt any further surgical steps. Ensure that no incision or further preparation is made on the incorrect side.
Double-Check with the Team: Verify with the surgical team, including the anesthesiologist and nursing staff, to cross-check the patient's identity, procedure, and correct surgical site.
Initiative
Communicate Clearly: Inform the entire surgical team about the discrepancy. Ensure that everyone is aware of the issue and the need to rectify it before proceeding.
Reassess the Situation: Gather the necessary documents and information to correct the error. This may include re-checking the patient's chart, speaking with the patient (if possible), and consulting with other team members.
Escalation
Notify the Senior Surgeon: Immediately inform the senior surgeon or the consultant in charge about the error. Provide them with all the relevant information to make an informed decision.
Involve the Theatre Coordinator: Make the theatre coordinator aware of the situation so they can assist with any necessary administrative steps.
Support
Document the Incident: Record the details of the discrepancy and the steps taken to address it in the patient's medical record. This ensures transparency and accountability.
Team Support: Ensure that the surgical team remains cohesive and supportive, understanding the importance of addressing the issue without blame, and focusing on patient safety.
On reviewing the clinic notes the patient has bilateral vascular problems and there is no indication of laterality. They were listed for the left side but the registrar states that they are sure the patient said it was the right 2nd toe. Should you proceed with the operation?
Given the lack of clear documentation regarding laterality and conflicting information from the registrar, it would be unsafe to proceed with the operation. Here are the steps to take:
Stop the Procedure: Ensure that the surgery does not proceed until the correct side is confirmed.
Clarify with the Patient: If the patient is still conscious and it is safe to do so, reconfirm with the patient which toe (right or left) requires the amputation.
Review All Documentation: Go through all available documentation, including any previous consultations, diagnostic reports, or imaging that might provide clarity on which side needs the procedure.
Discuss with Consultant: Discuss the discrepancy with a senior colleague or consultant for further guidance.
Postpone if Necessary: If you are unable to obtain definitive confirmation of the correct side, it is safer to postpone the surgery until the correct information is obtained.
Patient safety is the highest priority, and performing surgery on the wrong side could lead to serious consequences. Ensuring absolute certainty about the surgical site is essential before proceeding.
The patient is woken up by the anaesthetist. What would you tell the patient afterward and how would you deliver the information?
Choose a Quiet and Private Setting: Ensure the conversation happens in a quiet, private area where the patient feels comfortable and can speak freely.
Use Simple and Clear Language: Avoid medical jargon and explain the situation in terms the patient can easily understand.
Be Honest and Transparent: Clearly explain what happened and why you need their confirmation.
Show Empathy and Reassurance: Be compassionate. Reassure the patient that their safety is the priority and that the team is committed to providing the best care.
Allow Time for Questions: Give the patient an opportunity to ask questions and express any concerns. Answer them patiently and thoroughly.
Apologise for the Inconvenience: Acknowledge the inconvenience and stress caused by the situation and apologise sincerely.
What is a never event? Can you give some surgical examples?
A "never event" is a serious, preventable incident that should not occur if proper safety protocols are followed. These events are considered wholly unacceptable and indicative of underlying safety issues within the healthcare system. Here are some examples of never events:
Examples of Surgical Never Events
Wrong Site Surgery: Performing surgery on the wrong body part, such as operating on the left knee instead of the right knee.
Wrong Procedure: Performing a surgical procedure that was not intended for the patient, such as removing the wrong organ.
Wrong Patient Surgery: Performing a surgical procedure on the wrong patient due to misidentification or a mix-up in patient records.
Retained Foreign Object: Leaving a surgical instrument, sponge, or other foreign object inside the patient’s body after the operation is completed.
Wrong Implant/Prosthesis: Implanting the wrong type or size of prosthetic device, such as a hip or knee implant that is not suited to the patient’s anatomy or needs.
Intraoperative or Immediate Postoperative Death: The death of a patient in an ASA Class I patient (a patient who is healthy with no systemic disease) occurring during or immediately after surgery for reasons that are preventable.
Wrong Donor Organ: Transplanting an organ from a donor of the wrong blood type or otherwise incompatible donor.
Incorrect Specimen Handling: Incorrectly handling, labelling, or processing surgical specimens, leading to a misdiagnosis or inappropriate treatment.
These events are classified as never events because they are considered preventable through proper safety protocols and systematic checks, such as the use of surgical safety checklists, proper patient identification procedures, and standardised surgical site marking. Implementing and adhering to these safety measures can significantly reduce the occurrence of such events.
Tell me about the WHO Surgical safety checklist?
The WHO Surgical Safety Checklist is a tool developed by the World Health Organization to enhance the safety of surgical procedures. It aims to ensure that critical safety steps are followed consistently, thereby reducing the risk of complications and improving patient outcomes.
The checklist is divided into three distinct phases of a surgical procedure: before the induction of anaesthesia (Sign In), before the incision is made (Time Out), and before the patient leaves the operating room (Sign Out). Each phase corresponds to a specific time period in the normal flow of a procedure and requires the surgical team to pause and complete a series of checks before proceeding.
Phases of the WHO Surgical Safety Checklist
Sign In (before induction of anaesthesia)
Patient Identity: Confirm the patient's identity, the surgical site, and the procedure.
Consent: Ensure that informed consent has been obtained.
Surgical Site Marking: Confirm the site is marked appropriately.
Anesthesia Safety Check: Verify that the anesthesia machine and medication are ready and correct.
Allergies: Check for any known allergies.
Risk of Blood Loss: Assess the risk of significant blood loss and ensure that adequate IV access and fluids are available.
Time Out (Before Skin Incision)
Team Introduction: All team members introduce themselves by name and role.
Patient Details: Confirm the patient's identity, surgical site, and procedure again.
Anticipated Critical Events: Discuss any critical or unexpected steps in the procedure, the duration, anticipated blood loss, and any specific patient concerns.
Antibiotic Prophylaxis: Confirm that prophylactic antibiotics have been administered within the last 60 minutes if indicated.
Imaging: Confirm that essential imaging is displayed and properly labeled.
Sign Out (Before the Patient Leaves the Operating Room)
Procedure Confirmation: Confirm the name of the procedure performed.
Instrument and Sponge Counts: Verify that instrument, sponge, and needle counts are complete.
Specimen Labeling: Ensure that all surgical specimens are correctly labeled, including patient details.
Postoperative Plans: Discuss any key concerns for the recovery and management of the patient, including specific instructions for the care team.
What are the benefits of the WHO Surgical Safety Checklist?
The WHO Surgical Safety Checklist is a critical tool in modern surgical practice, designed to enhance patient safety and improve surgical outcomes. By ensuring that vital safety steps are consistently followed, it helps to create a culture of safety and teamwork within the operating room.
Benefits of the WHO Surgical Safety Checklist
Improved Communication: Enhances communication among surgical team members, ensuring that everyone is aware of their roles and the specifics of the procedure.
Error Prevention: Helps prevent common surgical errors such as wrong-site surgery, wrong procedure, and retention of foreign objects.
Patient Safety: Promotes the consistent application of safety practices, thereby improving overall patient safety and reducing the likelihood of complications.
Standardisation: Provides a standardised approach to surgical safety, which can be adapted to various surgical settings and procedures.