Avoiding never events in orthopaedics theatres: a quality improvement project

Area of Science:

• Surgical Safety
• Patient Care Improvement
• Healthcare Auditing

Background:

• Never events, critical patient safety incidents, occur in 54% of operating room cases.
• These events cause significant stress and compromise patient safety in trauma and orthopaedic settings.
• Adherence to surgical pause and imaging pause protocols is crucial for preventing such incidents.

Purpose of the Study:

• To reduce never events in trauma and orthopaedic theatres.
• To ensure theatre staff consistently follow surgical pause and imaging pause protocols.
• To implement regular audits for monitoring and improving protocol adherence.

Main Methods:

• Prospective study in trauma and elective orthopaedic theatres.
• Audits conducted by non-surgical team members on random days.
• Observation of adherence to surgical and imaging pause protocols, including patient verification and imaging confirmation.

Main Results:

• Substantial increase in compliance with surgical and imaging pause protocols observed.
• Corresponding reduction in the occurrence of never events.
• Theatre staff reported enhanced understanding and confidence in safety procedures.

Conclusions:

• Regular audits by non-surgical staff effectively improve adherence to safety protocols.
• This systematic approach significantly reduces never events in orthopaedic surgery.
• Continuous monitoring and education foster a culture of safety and precision in surgical practice.