Many of our prospective clients often tell us that they are working successfully towards a safer culture, and yet never-events and avoidable harm do not appear to be diminishing on a National basis.*
Let's look at NatSSIPs and LocSSIPs on which there is a renewed focus at this time. Otherwise known as the Five Steps to Safer Surgery.
LocSSIPs is a topic that we have masses of experience in, helping Trusts develop their own best practice in briefing, checklist and debriefing . We are privileged to witness many excellent demonstrations using Natsipps techniques but sadly, we occasionally meet individuals who think they don't need such aids to safety.
Very recently I was disappointed to witness a Clinician quite deliberately reading news reports on his Smartphone while a Safer Surgery Checklist was being read. Sadly his clinical colleague said nothing. Rest assured that the situation was rectified at the time. However this is still not unique, though happily rare.
We have a responsibility to ensure the importance of NatSSIPs and the reasons behind its introduction are understood. In our view (and others) the use of checklists and safety techniques is not a personal option, but a mandate and a necessary core function of professional surgical performance.
NatSSIPs is built around the aviation based concept of threat and error management. This came out of the original NASA funded research at the University of Texas under the late professor Bob Helmreich.
Threat and Error Management is three steps:
•AVOID – in an ideal world you would avoid everything that could possibly go wrong
•TRAP - But of course you can't avoid everything in the real World. What you haven't been able to avoid you would wish to trap, in order to minimise any errors resulting in potential harm.
•MITIGATE (read definition)- Finally, one needs to reduce the effects if harmful but to stretch the meaning of 'Mitigate' – to learn from failure and of course success.
How does this work in practice?
In healthcare, as in aviation, the 'AVOID' phase is accomplished by having a briefing (Handover or Safety Huddle) normally performed at the start of a working shift or day. This is where the team get together, share plans for what should happen, build situation awareness (Plan A) across the whole team and prepare themselves for what they hope won't happen (Plan B, plan C etc).
'TRAP' - The 3 steps of the WHO Safer Surgery Checklist fulfil this role.The checklist serves as a memory aid to ensure all necessary safety issues have in fact been completed. Note – it is a Checklist - not a TICK LIST. It is completion of the actual CHECK that is crucial and not the ticking of a box!
Finally, 'MITIGATION'. Debriefing sits here as a tool for learning not blame. In the case of a successful outcome debriefing is the opportunity to discuss what went well, why it went well and how we will try to ensure it goes well tomorrow and thereafter.
In the event that it has not gone well, rather than resorting to blame and finger pointing; this step serves to investigate why and how something went awry. How and why well-intentioned, well-trained people have perhaps made an error, with a view to genuinely learning lessons and moving forward effectively for the whole team and ultimately the organisation and the profession.
Duty of Candour sits here too and is of course a legal, professional and a compassionate necessity.
After all, quite apart from the safety aspect, who gains the most respect? Someone who accepts and owns up to their own fallibility or someone who seeks to hide it?
Atrainability would be delighted to assist you in implementing LocSSIPs for your teams, please get in touch to arrange an informal phone chat at your convenience.
*Source: Never events data, click here