252 / Five Steps to Safer Surgery

United Kingdom
Classification of the PSP
Type of Patient Safety Practice Potentially Safe
 
Clinical Practice (CP)
Related practices from PaSQ database
"Best fit" category of the reported practice
Communication
Other There is no specified text here
Topic of the reported practice
Quality management system
Aim and the benefit of the Patient Safety Practice
 
Implementation of The Five Steps to Safer Surgery (WHO Surgical Safety Checklist with team brief and debrief)is aiming to improve the culture in the way that theatre teams work together, to improve communication and reduce error resulting in patient harm during perioperative care.
Description of the Patient Safety Practice
 
Implementation of the WHO Surgical Safety Checklist is a key element of the WHO second global challenge, Safe Surgery Saves Lives.

The National Patient Safety Agency issued a Patient Safety Alert in January 2009 with the requirement that the Checklist should be used for every surgical procedure and use recorded in the patients’ health care record. The Alert was produced in partnership with the relevant Royal Colleges and professional associations and included an adapted version of the Checklist for the NHS. http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59860

Implementation was supported by the Patient Safety First campaign, a two year campaign for the NHS in England based on social movement. It quickly became apparent that to achieve the required cultural change in theatre teams that the Checklist needed to be introduced with a team brief and debrief at the beginning and end of the theatre list.

The NPSA Alert supported local adaptation of the Checklist to increase clinical engagement and address specific clinical risks. It recommended that adaptation should be undertaken in accordance with local clinical governance procedures. The NPSA also developed a small number of specialty specific Checklists in collaboration with the relevant Royal Colleges. These have been produced for cataract surgery, interventional radiology and maternity.
A variety of resources have been developed by the NPSA and Patient Safety First to support implementation of the Five Steps to Safer Surgery. These include a How to Guide, videos and Quick Guide to Brief and Debrief. http://www.patientsafetyfirst.nhs.uk/Content.aspx?path=/interventions/Perioperativecare/

A variety of national and local workshops have been undertaken to provide up to date information and the opportunity for people to share experiences and best practice. The need for training in human factors has been highlighted at these workshops. The NPSA has continued to work in collaboration with the Royal Colleges and professional associations to ensure successful implementation of the Five Steps to Safer Surgery which has included incorporation into professional standards and educational curricula.

A Safer Surgery Week was held in September 2012 with the objective of improving implementation of the Five Steps to Safer Surgery and reducing the number of serious surgical incidents occurring e.g wrong site surgery, retained instruments and swabs and wrong implants. This was undertaken in collaboration with the relevant Royal Colleges and professional associations and included a series of webinars from high profile presenters as well as local activities for theatre teams to engage in. http://www.patientsafetyfirst.nhs.uk/Content.aspx?path=/Campaign-news/safer-surgery-week-2012/

Imperial College London and Imperial College Healthcare NHS Trust were awarded a National Institute for Healthcare Research (NIHR) grant to undertake an in-depth national evaluation of the Checklist in England, with emphasis on Checklist usability and contribution to safer care delivery. There are two programmes of research within this evaluation:

Evaluating the diffusion of the Checklist and its usage across NHS organisations and evaluating the impact of the Checklist on clinical outcomes.

These programmes encompassed the following overall aims:
•    To find out how the Checklist is currently used in operating theatres.
•    To investigate theatre and non-theatre staff’s perceptions of Checklist usage and efficacy, and if/how these perceptions change over time.
•    To assess the barriers and enablers to successful implementation.
•    To correlate these findings with measures of safety culture in the relevant Trusts.
•    To assess how variation in Checklist usage and perceptions relate to intra-operative and post-operative outcomes.

Data is currently being compiled for dissemination in peer reviewed journals and will be available in early 2013
Attachment of relevant written information and/or photos, as appropriate
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Effectiveness of the Patient Safety Practice
 
Degree of implementation of reported practice
Yes, partly
Level of implementation of reported practice
Regional or national level
Specific and measurable outcome for the reported practice were defined
Yes
A baseline measurement before implementation of the reported practice was obtained
Yes
A measurement after full implementation of the reported practice was obtained
Not known
Evaluation of a "positive" effect of the reported practice on Patient Safety
Effect not known or the intervention has not yet been evaluated
Type of before-and after evaluation
Both/mixed (qualitative and quantitative)
Enclosure of a reference or attachment in case of published evaluation's results
http://www1.imperial.ac.uk/medicine/about/institutes/patientsafetyservicequality/research_themes_2/cpssq_research_themes/surgical_checklist/
There is no specified text here
Health care context where the Patient Safety Practices was implemented
 
Hospital
Transferability
 
Successful implementation of this Patient Safety Practice in other health care settings than above stated
No
Specification of implementation in another health care setting(s)
Community care facility
Successful implementation's level  of this Patient Safety Practice across settings
There is no specified text here
Involved health care staff
 
Physicians
Patient Involvement
 
Direct service user's involvement as integral part of this Patient Safety Practice
Yes
Specification of the service users or their representatives' involvement in the implementation of this Patient Safety Practice
Patient(s)
Relative(s)
Patient representative(s)
Point of time in which service user or their reprasentatives' involvement takes place
During the development of the Patient Safety Practices
During implementation of the Patient Safety Practices
During evaluation of the Patient Safety Practices
Active seeking of service users' opinion, feedback, experience, etc. as integral part of this Patient Safety Practice
No
Short description of the service users' level of involvement
Collaboration, such as co-designing a Patient Safety Practice or active partnership in implementation
Public accessibility of information regarding this Patient Safety Practice to patients and citizens/service users
Yes
List of sources where public information is accessible
NPSA website
Implementation of the Patient Safety Practice
 
Existing collaboration with other countries or international organisations related to implementation of this Patient Safety Practice
Yes
Problems encountering in the implememntation course of this Patient Safety Practice like lack of motivation, no management support, etc.
Yes
List of the most prevelent difficulties encuntered during implementation of this Patient Safety Practice
No management support
No motivation among staff
Staff or management did not recognise the need for change
List of the most prevalent drivers for a successful implemetation of this Patient Safety Practice
There is no specified text here
Use of any specific incentives to enhance motivation while implementing this Patient Safety Practice
Yes
Description of used incentives, if any.
When the NPSA issued the Alert this places a requirement on all NHS organisations to comply with recommendations.

The Patient Safety First campaign was based on social movement.

We have worked in collaboration with all relevant professional organisations to engage staff in this initiative
Existence of support or approval by the clinical or hospital management or any other hihg level authority in the implementation process of this Patient Safety Practice
Yes
Costs of the Patient Safety Practices
 
Completion of cost calculation related to this Patient Safety Practice
No
Total number of person days required to implement this Patient Safety Practice
Clinical staff: There is no specified text here
External consultants: There is no specified text here
Support staff: There is no specified text here
Managerial staff: There is no specified text here
Others: There is no specified text here
Not relevant: There is no specified text here
Total number of person days required for training as preparation for implementation of this Patient Safety Practice
Clinical staff: There is no specified text here
External consultants: There is no specified text here
Support staff: There is no specified text here
Managerial staff: There is no specified text here
Others: There is no specified text here
Not relevant: There is no specified text here
Total cost in Euro of specific equipment (machines, software, communications supplies, etc.) needed to support implementation of this Patient Safety Practice
There is no specified text here
Associated cost with a work reduction or foregoing in order to deliver this Patient Safety Practice
There is no specified text here
Contact information
 
Name: Joan Russell
Country: United Kingdom
Organisation: NHS Commissioning Board
E-mail: joanrussell@nhs.net
Phone: There is no specified text here
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