AVOIDable medical errors in invasive procedures: Facts on the ground – An NHS staff survey

Article type: Research Article

Authors: Omar, Islam^a; | Hafez, Ahmed^b | Zaimis, Tilemachos^c | Singhal, Rishi^d | Spencer, Rachel^e

Affiliations: [a] Northern Health and Social Care Trust, Antrim, UK | [b] Royal London Hospital, London, UK | [c] Wirral University Teaching Hospital NHS Foundation Trust, Birkenhead, UK | [d] University Hospital Birmingham NHS Foundation Trust, Birmingham, UK | [e] Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry, UK

Correspondence: [*] Address for correspondence: Islam Omar, Northern Health and Social Care Trust, Antrim Area Hospital, Bush Rd, Antrim BT41 2RL, UK. E-mail: islamfawzyomar@hotmail.com

Abstract: BACKGROUND:Never Events represent a serious problem with a high burden on healthcare providers’ facilities. Despite introducing various safety checklists and precautions, many Never Events are reported yearly. OBJECTIVE:This survey aims to assess awareness and compliance with the safety standards and obtain recommendations from the National Health Service (NHS) staff on preventative measures. METHODS:An online survey of 45 questions has been conducted directed at NHS staff involved in invasive procedures. The questions were designed to assess the level of awareness, training and education delivered to the staff on patient safety. Moreover, we designed a set of focused questions to assess compliance with the National Safety Standards for Invasive Procedures (NatSSIPs) guidance. Open questions were added to encourage the staff to give practical recommendations on tackling and preventing these incidents. Invitations were sent through social media, and the survey was kept live from 20/11/2021 to 23/04/2022. RESULTS:Out of 700 invitations sent, 75 completed the survey (10.7%). 96% and 94.67% were familiar with the terms Never Events and near-miss, respectively. However, 52% and 36.49% were aware of National and Local Safety Standards for Invasive procedures (NatSSIPs-LocSSIPs), respectively. 28 (37.33%) had training on preventing medical errors. 48 (64%) believe that training on safety checklists should be delivered during undergraduate education. Fourteen (18.67%) had experiences when the checklists failed to prevent medical errors. 53 (70.67%) have seen the operating list or the consent forms containing abbreviations. Thirty-three (44%) have a failed counting reconciliation algorithm. NHS staff emphasised the importance of multi-level checks, utilisation of specific checklists, patient involvement in the safety checks, adequate staffing, avoidance of staff change in the middle of a procedure and change of list order, and investment in training and education on patient safety. CONCLUSION:This survey showed a low awareness of some of the principal patient safety aspects and poor compliance with NatSSIPs recommendations. Checklists fail on some occasions to prevent medical errors. Process redesign creating a safe environment, and enhancing a safety culture could be the key. The study presented the recommendations of the staff on preventative measures.

Keywords: Never Events, avoidable medical errors, claims, NHS, patient safety, survey

DOI: 10.3233/JRS-220055

Journal: International Journal of Risk & Safety in Medicine, vol. 34, no. 3, pp. 189-206, 2023