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Never events and the 10,000ft rule

Widely reported in the news recently was the story of a gentleman who went into the hospital for a routine bladder procedure and left having received a circumcision.

70-year-old Terry Brazier was awarded £20,000 in compensation following the "never event" at Leicester Royal Infirmary last summer. The hospital said it was "deeply and genuinely sorry".

The news story shows that never events continue to happen. In my experience, there are as many of these incidents occurring today as there were before the focus on never events started within the healthcare sector.

Receiving a circumcision instead of a Botox injection into your bladder is, I suppose, unfortunate and distressing. But think of what else could have happened.

We know of one case where a young patient was supposed to have scar tissue removal on his scrotum but received a vasectomy instead. This mistake was truly devastating for the young man, and impossible to reverse in this instance. The surgical team also suffered immense distress when they realized and that is a subject for another day.

It makes you wonder how these never events come about. Surgeons don't purposely set out to operate on the wrong side or to carry out the incorrect procedure. But these never events are not diminishing statistically, despite apparent safeguards put in place to protect against them. And I find that extremely alarming.

One of the things we find, when asked to go into a hospital and try to help prevent further incidents and rebuild morale, in the wake of an avoidance harm incident, is that interruptions and distractions often feature.

Last year, I was training and coaching in a surgical unit, when I was called into the neighbouring theatre which had just experienced their own never event. It was a wrong side nerve block, thankfully resulting in no devastating harm, but certainly with the potential to cause real damage to the patient. Distraction was a factor there. The anaesthetist and assistant had been chatting about their respective weekend social life. That was just after they had completed the mandatory 'Stop before you Block' check.

A good friend of mine, a senior Emergency Department Consultant told me the biggest safety threat of all is managing your environment, both externally (interruptions) and internally (self distractions). Just not thinking or concentrating.

In the aviation profession, we follow the 10,000ft rule. When flying commercial airliners, anytime you're operating below 10,000ft above the ground, you enter a social lockdown mode. There's no discussing your next round of golf, or your plans for the weekend. We call it the 'sterile flight-deck'. It equates roughly to the first and last 10 minutes of the average commercial flight but as you descend below 10,000 feet altitude is a mandatory safety check so we combine the two at that convenient moment.

There are times and places for social chit-chat. There are times and places for focusing on the task at hand.

When pilots aren't concentrating on flying the plane, that's when things tend to go wrong. It could be something relatively harmless like a bit of speeding (!), or it could be more severe like flying too close to another aircraft, or a hill, or radio mast.

It's positive to see some hospitals now introducing their own 10,000ft rule. The team are advised of the threats to safety at the briefing stage and reminded to make the safety call. Someone in the team says "10,000ft", and everyone goes silent. There are no interruptions, no distractions, focus. They could also be briefed to announce any concerns that they might notice and ensure a response – think of the 'Gorilla' video! Attention mechanism etc.

When you reach the crucial part of the procedure, the part where things have the potential to go wrong, that's when the 10,000ft rule is activated. You don't allow anyone else to enter the room and phones are switched to silent.

In the case of the gentleman receiving the circumcision, the compensation payout and negative PR can help focus attention on the causes and prevent them from happening again. A lot depends on how embarrassing the never event is for the hospital in question.

There are never any winners when there is avoidable harm. But I'm still not sure that everyone in healthcare takes never events as seriously as they should.

Safety 2 to the core
Complacency at play in healthcare