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This study explored the human factors findings from reviewing the causes of 9 surgical ‘never events’. Never events are a list of patient safety adverse events which are known to result in severe harm or death (e.g. wrong-site surgery).

Results:

Findings from the 9 never events were grouped into 6 categories of contributing factors. All incidents involved a combination of the different categories.

1. Workspace/enviro factors: Some events were triggered by error provoking conditions influenced by workspace/enviro factors, such as when surgeries were switched into another theatre with a different layout to where the surgical team normally operated. Notably it was often “small changes that made a big difference to how left and right [sides of the body to be operated on] were interpreted” (p213).

Inadequate planning led to equipment being needed in more than one place at the same time & the design of some theatres led to visual cues being lost when the table was rotated. In another study, equipment problems in theatres were found in 1 in 7 theatres. [Unfortunately, the factors leading to “poor planning”, their words, weren’t further discussed.]

2. Culture & organisation: Issues in these areas meant staff coped with time pressures, accepting shortcuts and not following procedures as the norm. E.g. when surgeons don’t have time to see the patient before surgery or rushed in without reading the notes and thus relying on memory. Work design led to staff changes happening during procedures, introducing interruptions & distractions; e.g. a key staff member called away from the theatre just as the procedure started.

3. Communication: Comms through written or computer records played some role in every case. Interestingly, common abbreviations for left & right had very different meanings to doctors in different specialities, eg the initials RT “meaning radiotherapy to the oncologists but right to the surgeons” (p214). Even the definition of groin had a different meaning in two different medical teams.

Circling some words in the notes led to the “perpetuation of mistaken information as did preprinted labels” (p215). Info within notes missing was another common issue, with info required for clinical decision-making missing in 15% of cases in another study – requiring surgeons to make decisions in the absence of the info.

In 7 of 9 cases the site for the procedure was either not marked or not marked properly, seen as an issue associated with task design. Authors note that site marking isn’t straightforward for internal procedures.

In all cases it was evident that the World Health Organization surgical safety checklist was seen as important, but when it was seen by the lead surgeon as something to tick-off quickly or not used as intended then issues weren’t identified early enough and “people with doubts did not speak up” (p215).

A range of non-technical skills were identified in the never events.

In discussing the findings, authors state that when never events occur there is a pressure for organisations to demonstrate that something has been done to prevent reoccurrence. However, as their findings show, the events have multiple upstream factors yet the “easiest course of action is to address each cause with its own action plan that can be completed quickly to report to the Board” (p215).

They discussed previous findings into procedural non-compliances, finding there to be too many procedures to remember; multiple rules on the same topic; often being difficult to access; & too lengthy to read quickly. They note “it is likely that [companies] need to simplify and reduce the number currently in existence and make them relevant to the areas where they apply” (p215).

In conclusion, they state that the types of issues found in these never events “cannot be adequately addressed by the action plans prepared in response to an investigation that target each individual cause — things are never that simple — instead the causes should be seen as a reflection of the current state of safety within the organization, showing the underlying cultural and systems issues that need to be addressed at a wider level than that of the incident itself” (216).

Authors: Susan Burnett, Beverley Norris, Rhona Flin, 2013, Journal of Patient Safety and Risk Management

Link: https://doi.org/10.1177%2F1356262212474650

Link to the LinkedIn article: https://www.linkedin.com/pulse/never-events-cultural-systems-issues-cannot-addressed-ben-hutchinson