SALG has not been involved in the production of these projects, and as such, we cannot formally endorse them. However, the group is keen to support local safety projects and hopes that this page will help share ideas and promote discussion. The projects are not formally peer-reviewed. Safety initiatives can have unintended consequences, and those wishing to implement projects should be alert to this possibility.
Improving risk assessment for emergency laparotomy
An objective assessment of risk should be made and documented before every emergency laparotomy
- Few of the hospitals contributing to the National Emergency Laparotomy Audit (NELA) met this standard
- Croydon University Hospital reports how they changed their processes to make sure risk assessment is completed
The first NELA report, released this June, highlighted that the risk of death was not documented for nearly half of patients having emergency laparotomies, and that for high-risk patients, a lack of documentation was associated with a failure to provide both consultant review and postoperative critical care.
Maria Chereshneva and Vanessa Cowie, at Croydon University Hospital, wanted to improve their local process for risk assessment. They introduced mandatory P-POSSUM risk scoring by an anaesthetist prior to theatre and found that documentation of risk assessment rose to 100% of cases, from 20% in the previous year. Their laparotomy proforma is still in development but is shared here.
They found that the process of calculating and recording the risk of death made the anaesthetists who were assessing the patients for theatre more proactive in involving senior colleagues (both anaesthetists and surgeons), and in planning for postoperative critical care.
Junior anaesthetists also began to discuss risk more openly with the patients themselves, helping them to make better informed decisions about their care. The risk assessment process is currently being incorporated into a new emergency laparotomy proforma in order to make sure all of patients receive appropriate care, based on their individual risk.
This project was featured at the Safe Anaesthesia Liaison Group Patient Safety Conference 2015.
A debrief grid
A debriefing tool that includes the whole theatre team:
- Team debriefing is a key safety intervention in high risk industries.
- Debriefing is difficult as staff members traditionally need to come back together at the end of the day for the debrief.
- This new tool offer a non-confrontational way for teams to contribute to a debrief over the course of the day.
- The grid is a debrief record, that is analysed and actioned later.
Debriefing is a crucial way to make sure learning from a list is captured for the future, and has been adopted across most safety critical industries. However, despite a series of recommendations and requirements for debriefing in healthcare settings, it is often done poorly or not at all. There are many barriers to effective debriefing, not least that different staff members finish in the theatre at different times.
New national safety standards for invasive procedures in England are the latest in a series of documents recommending or requiring that a debrief takes place along with that it is recorded and actioned.
A team at the Royal London Hospital have developed a ‘live’ debriefing grid, to be displayed on the theatre wall and added to by team members whenever they have time or comment, as the day goes on. The grid is discussed at the team brief, and the 'sign out' for each case can serve as a prompt to ask the team for suggestions for the debrief. The completed grids are then put into a weekly report which is reviewed by the governance team and displayed on the theatre safety board.
The debrief grid was devised up by Ashley Parker, an anaesthesia trainee, on a MATCH team training day, and developed with consultant anaesthetist Annie Hunningher.
The team have found that after introducing the tool, the debriefing rate increased from 33% to 81%, and that staff are boosted by seeing the positive feedback as well as the negative points and are engaged in action plans for improving safety.
Animated videos to share learning from incidents
- How well does your organisation share the lessons learned from incidents and adverse events?
- Can all staff easily access serious incident investigation reports?
- Is there a process to make sure the important messages get to transient staff groups, such as doctors in postgraduate training?
Arwa Abdel-Aal, an FY2 doctor from East Midlands Deanery, wanted to help her trust, University Hospitals of Leicester, to reach junior doctors of different grades and specialities. To do so, she and colleagues developed a series of animated videos to spread the word about learning from incidents. An example is below.
Other videos are posted on a YouTube channel.
In her hospital, clinicians and managers discuss SUI reports to determined the important lessons to learn. Then Arwa and her colleagues make up realistic, but not real, scenarios based on these lessons, and make these into an animated video.
The video structure generally includes the story, a reflective part and a final tips part. Because the cases presented are fictional, the actual SUIs are kept confidential, but the learning can still be shared both locally and nationally, including through social media.
Arwa's intiative won a prize for the best safety project at the 2015 GMC annual conference.
In her poster, Arwa points out in that as well as promoting learning from particular events, this project also promotes a cultural shift in the way junior doctors see patient safety and the importance of taking steps to recognise and learn from incidents and mistakes more generally.