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Learning from safety incidents

We take patient safety very seriously and have good training, systems and equipment in place to provide high quality care. However occasionally errors do occur and we want to do all we can to learn from them and try to prevent them happening again.

Never Events are one type of safety incident. They are defined as ‘serious largely preventable patient safety events that should not occur if preventable measures have been implemented’ (Department of Health 2012).

There are definitions for twenty-five Never Events, which are categorised as Surgical, Medications, General Healthcare, Maternity, Mental Health. Twenty three of these relate specifically to the activities of an acute Trust.

One of the possible Never Events relates to retained items following surgical intervention.

During a three year period 2010-2013 over 500,000 surgical procedures were carried out at Sheffield Teaching Hospital NHS Foundation Trust and of those, eleven patients who underwent surgical/invasive procedures were identified as having had items of medical equipment (predominantly an individual swab/dressing) retained in their bodies after surgery.

Although remedial actions were taken quickly in each case it was clearly a concern that such serious untoward incidents occurred. Therefore the Trust, along with Sheffield Clinical Commissioning Group proactively commissioned an independent review to provide an opinion regarding the systems, behaviours and culture at Sheffield Teaching Hospital NHS Foundation Trust with respect to the likelihood of such ‘Never Events’ recurring.

The conclusion of the review was that there were areas where learning or practice could be improved but the overall conclusions were as follows:

“Following a review of all appropriate documentation, observing operating theatre procedures and undertaking interviews with crucially placed staff no evidence has been found to suggest that STH has an unrecognised systemic patient safety problem.

On the contrary, the evidence indicates that, apart from a number of outliers, the vast majority of the activities undertaken by STH with respect to patient safety meet the highest standards. However, where there appears to be
room for improvement recommendations have been in those respects.”

“The overwhelming majority of medical equipment items retained by patients at STH during the period covered in this External Review are similar in nature to those retained by patients at other NHS Trusts. Hence there does not appear to be an atypical pattern with respect to the items of
medical equipment being inadvertently retained by patients at STH.”

“From the reports of the investigations into the surgical/invasive procedures discussed there appears to be no discernable pattern of behaviour which suggests that Sheffield Teaching Hospital NHS Foundation Trust has a systematic problem with patient safety. No member of any surgical or theatre team has been involved in more than one of the Never Events reviewed. Each of the Never Events which took place did so due to a unique set of circumstances prevailing at the time. They also appear to have taken place at random over the three year period covered by the External Review.”

“Sheffield Teaching Hospital NHS Foundation Trust has no patient safety alerts outstanding and therefore patients are being protected as per national guidance.”

In respect of the areas for improvement, all recommendations of the External Review have been considered and a detailed action plan has been developed. A number of the actions which relate to Sheffield Teaching Hospital NHS Foundation Trust have already been completed. The report and action plan are available to read by clicking here. The conclusions of the report and the action plan have also been shared with the patients who were involved in the eleven incidents wherever possible.

The action plan has been agreed by the Healthcare Governance Committee who will also be responsible for monitoring progress on a quarterly basis.


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