Why are intra-operative surgical ‘Never Events’ still occurring in NHS operating theatres, what can be done to address barriers to safer surgery, as well as address how Human Factors can reduce patient harm?

Intraoperative ‘Never Events’ persist despite the Worlds Health Organisations (2009a) Surgical Safety Checklist (SSC) and National Safety Standards for Invasive Procedures (2023). This Delphi study and WHO Surgical Safety Checklist (SSC) thematic analysis examined why intraoperative ‘Never Events’ occur in the National Health Service (NHS). Surgical Safety Checklist research papers are in abundance, but theatre safety experts' direct research is scarce. The author has worked in operating theatres since 1996 and is now the Associate Divisional Director for Theatres, Critical Care, Anaesthetics and Pain at a Foundation NHS Trust. This study investigated why ‘Never Events’ occur in NHS England operating theatres where invasive operations are conducted and how theatre workers and the organisation might prevent intraoperative harm. Golden themes discovered adherence, culture, communication, leadership, training, human factors, and champions. Since the National Safety Standards for Invasive Procedures (NatSSIPs) were introduced, 2015 and 2023, to demonstrate the knowledge, skills, and attitudes required to ensure the safety of invasive treatments thereby minimising patient harm and 'Never Events' there has not been a significant decrease in the number of reported instances. The introduction of NatSSIPs was an attempt to ensure that the clinical approach is the same regardless of the location, time, and resources available. The research consisted of National Health Service (NHS) theatre Managers, Matrons, and Educators. The study employed quantitative and qualitative methodologies. This research methodology sought to adopt a positivist-functionalist which was adopted towards a more pragmatic approach. The chosen research method was action research based on three Delphi rounds with a representative sample (24% or 33) of NHS England Trusts from all seven regions, an NPAG questionnaire, and four Focus Groups (11% or fifteen NHS Trusts) comprised the research design (N=1 Focus Group consisted of 3 x Private healthcare providers). Multiple data gathering methods and methodological triangulation confirmed, reinforced, and broadened the conclusions. 3 The key hidden coding themes were ‘education’ and ‘adherence’, with ‘Staff welfare’, ‘Time’, ‘Resources’, ‘Civility’, and ‘Process’ under ‘Human Factors’. The research identified three themes: ‘dissident worker attitudes,’ ‘culture,’ and ‘leadership.’ These may offer exciting and worrisome intraoperative patient safety insights. Finally, ‘Never Event’ research and generic patient safety research seek to understand how individual and group behaviour interacts inside organisations to coordinate a complex process and achieve the intended outcome safely and effectively. Multidisciplinary team (MDT) dynamics, roles, and objectives, as well as increasing pressure to undertake elective activities and growing waiting lists, make the workplace tough and stressful, which can lead to errors and patient harm. The multidisciplinary team needs resources, tools, training, and knowledge to safely and efficiently administer the World Health Organisations’ Surgical Safety Checklist to reduce intraoperative patient harm. With strong leadership and proper resources, healthcare practitioners may experience a shift in varied ideas and Surgical Safety Checklist culture. The National Health Service (NHS) ran a ‘Never Event’ framework consultation from the 7th February to the 5th May 2024, which is worth reviewing. The consultation addresses Care Quality Commission (CQC) and the Health Safety Investigation Branch (HSIB) studies (HSIB 2021a) that demonstrated barriers to ‘Never Events’ are insufficient to avoid incidents. Does the ‘Never Events’ concept improve patient safety across the board? NHS England asks. The consultation could drastically alter intraoperative ‘Never Events’ reporting.