Blundering hospital staff allowed a patient under general anaesthetic to fall from an operating table headfirst while undergoing surgery.
The incident – one of two serious surgical errors at the city’s Western General Hospital – sparked a major inquiry into safety within the region’s operating theatres.
Incredibly, the investigation found that theatre staff are being distracted by MOBILE PHONES during operations as well as idle chatter from fellow staff. The inquiry has led to a series of new rules including:
• Compulsory training of 1200 staff
• A ban on talking at key times during operations
• Daily meetings to improve patient safety
• Sanctions for staff who fail to meet the new standards
Patient who slid off table
THE first incident which sparked the major probe into safety in operating theatres saw a patient slide from an operating table while they were knocked out by a general anaesthetic.
The table was tilted to “an extreme position of head down and left lateral tilt” to allow the surgeon access to the area he needed to operate on.
Ten members of staff had been allocated to the case, with all present at the start of the procedure except an anaesthetic trainee, who had decided to go for lunch.
A sheet was placed over gel pads, which are intended to grip the patient, but no concerns were raised by any member of the team.
As the operation progressed, the surgeon asked for the operating table to be tilted further so he could get a better view of the appendix. One member of the team commented on the “very marked tilt” in the table but no action was taken.
The surgeon then requested surgical clips, and stepped back from the operating table to look at the surgical tray, as a scrub assistant also moved away.
At this point, the unconscious patient “slid off the operating theatre and landed on the floor” remaining on the sheet with their back on the ground.
It is understood that the patient landed on their shoulder first and as the procedure was keyhole surgery, their insides were not exposed at the time.
An urgent call for help was made and the other staff rushed to the room to help. The patient was then lifted back to the operating table.
Worried theatre workers examined the patient for internal and external injuries, but none were found. The operation was then completed.
Once they woke up, the patient was told about their fall and received an apology.
Following the incident, an investigation was launched, with the case classified as a “significant adverse event”. All staff were interviewed.
It was found that “multiple contributory factors have actually or potentially contributed to this error”.
No restraints or straps were used and a sheet was placed on gel pads, making the table more slippy.
“Situation awareness” of staff in the operating theatre was described as “low”. It was also revealed that there was “inadequate team working and communication” amongst the operating theatre workers, whose roles were not clearly identified, contributing to the incident.
The safety culture within the operating theatre was described as “not one with high vigilance to patient safety”.
It is recommended that placing patients in extreme positions should be discussed at greater length and “recognised communication strategies” should be used in future.
Swab left inside body
The second major blunder, in the Western General Hospital’s colorectal theatre, occurred on May 1 this year.
The patient was knocked out and brought into the theatre at 11am, with a surgical checklist carried out before the patient was cut open. A four-hour operation was then carried out.
According to the official investigation report, it appeared the operation was “uneventful” .
However, a final count of swabs – carried out by two highly trained staff nurses – found that one was missing. Following a search, a blood-soaked swab was found in the patient’s abdominal cavity and removed. The patient was sewn up, with the team happy everything was accounted for.
The patient initially made a good recovery, with their bowel function returning to normal.
However, five days later they were given an X-ray after developing new symptoms.
The presence of a possible foreign object – believed to be a swab – was seen on the image.
The patient had to go under the knife once again to remove the rogue material from the abdomen, but there were complications in their recovery.
They were left critically ill in intensive care for a “prolonged” period. The patient was eventually sent home after recovering.
Once again, it was found that several factors had contributed to the error.
Small swabs were used, increasing the chance of them becoming lost. Increased visibility swabs are available to buy, but were not used for this operation.
The “situation awareness” of a scrub nurse counting the swabs “may have been compromised by recent change in circumstances, anxiety or distraction during a period of high work intensity”, the investigation found.
A “steep hierarchy gradient” was described in the team, with “little teamwork and support between professional groups”. The structure within the team acted as a “barrier to communication”, while some staff said they felt “unsupported”.
Distractions in the theatre included staff coming and going to take breaks and prepare for other cases. Chatting and use of mobile phones were described as sources of distraction.
The report said: “This may impact on the situational awareness of individuals and increase chance of error”.
The system for ensuring items are not left in patients was criticised, with investigators saying: “The swab count that occurs at the end of the procedure should not be relied on as the sole defence against a retained item.”
The case has been discussed throughout NHS Lothian, with a meeting with the theatre teams at the Western organised to discuss lessons learned. It will be used as a case study next year in theatre team training and form part of a ‘learning from adverse events’ talk next month.
Events that should never happen
The incidents – which a senior MSP today called “any patient’s worst nightmare” –occurred at the city’s Western General Hospital and sparked an inquiry into safety in the region’s operating theatres.
Around 1200 staff are to be given urgent training after the probe revealed serious cultural issues, including poor teamwork between NHS workers and even that staff were being distracted by mobile phones and engaging in idle chat as they held the lives of patients in their hands.
In a radical new approach, health bosses are to look to the aviation, nuclear power and offshore oil industries in a bid to lower the risk of the potentially catastrophic human errors being repeated.
Findings of the internal NHS Lothian investigation, produced last month, have been revealed by the Evening News after being obtained under Freedom of Information legislation.
Lothians Labour MSP and shadow health secretary Neil Findlay today described the cases as “shocking” and said issues highlighted by the investigation were deeply worrying.
He added: “It’s only right and proper a full investigation was carried out but the revelations about staff behaviour are a real cause for concern and while the training is welcome, to ensure incidents like this aren’t repeated, the cultural issues need to be looked at.”
The two avoidable incidents, both in May, sparked the probe into safety in Lothian operating theatres.
In the first, an unconscious patient slid off an operating table, which had been tilted to allow the surgeon to reach an inaccessible area, despite a team of ten working on the procedure.
No restraints were used and a sheet had been placed over gel pads designed to add grip.
The second case saw a surgical swab left inside a patient’s abdominal cavity following an operation, causing complications that could have proved fatal.
The error was only discovered five days later when the patient was given an X-ray to investigate abnormal swelling. A further procedure was needed to remove the foreign object, causing complications that led to two stints in intensive care, one of which was “extended”.
The health board has admitted that “a number of other incidents” have occurred in recent months, leading to separate investigations. The revelations have raised serious fears over the safety of the tens of thousands of patients who go under the knife in the region’s hospitals after revealing deep-rooted cultural issues.
Dr Nikki Maran, a consultant anaesthetist at the Royal Infirmary and associate medical director with NHS Lothian, who helped carry out the investigation, said one of the new measures would be a ban on chatting at key times during operations – in a similar approach to rules for airline pilots, who must only speak about the task at hand during take-off and landings.
The investigation found that “extraneous conversation and use of mobile phones in theatre were mentioned as sources of distraction” by staff, increasing the chances of errors.
“We are obviously extremely disappointed that this has happened in operating theatres in NHS Lothian,” Dr Maran said. “We call these sort of incidents ‘never events’, not because they never happen, but because they should never be allowed to happen.
“We are planning to deal with them in a way that doesn’t just look at focusing on individuals, rather on looking at the whole system, which is likely to be a much more comprehensive way of addressing safety.
“In other industries they have used science of human factors to understand safety and make improvements. We can integrate that into the training for health professionals.”
Inspections will take place after staff have been given training to ensure they are sticking to new rules. If they “undermine” the objectives, they could be removed from operating theatres as a last resort.
Other new measures to be introduced on the back of the findings include daily safety briefings in theatre suites and weekly meetings to discuss things that go wrong and safety measures.
The internal investigation report said that the two incidents had revealed “deficiencies in a number of different factors in the levels of defences needed to maintain a safe environment” in theatres. It added that common factors had been identified between the two incidents, indicating deeper problems existed.
Dr Maran said the problems identified were not unique to NHS Lothian and dangers uncovered were likely to be repeated in operating theatres across Scotland and the UK.
Tory health spokesman Jackson Carlaw said the “alarming” occurrences in NHS Lothian theatres would “feed any patient’s worst nightmares ahead of going in for an operation”.
He added: “While such incidents are rare, it’s crucial NHS Lothian moves to reassure patients the likelihood of this occurring again is extremely remote.
“Training is essential and I’m glad that’s ongoing, but it’s also critical the Scottish Government’s eroding of the NHS does not extend to the operating theatre.”
It is planned that new training will be given to all staff who work in NHS Lothian theatres by March next year.
The Royal College of Surgeons Edinburgh backed the “human factors science” approach now being adopted by NHS Lothian.
Ian Ritchie, the organisation’s president, said: “Patient safety is an issue which concerns all those who care for patients, and lies at the heart of medical practice. All surgeons have a primary responsibility to participate in established procedures and to develop new measures to improve patient safety.
“The Royal College of Surgeons of Edinburgh is strongly committed to improving standards of patient safety through education and training and by supporting research into human factors which may prevent or mitigate patient harm.”
Health bosses said the retraining represents a significant investment in terms of staff time and serves as an indication of the seriousness with which the health board is taking the damning report.Dr David Farquharson, NHS Lothian’s medical director, said that while incidents in operating theatres were rare, one was “too many”.
He added: “These events are taken very seriously and investigated fully. Action plans are put in place to ensure lessons are learned and any changes are made to the strict policies and processes in place to reduce risks during operations.”
A spokeswoman for the Scottish Government said it had received assurances NHS Lothian had investigated the two incidents, apologised to the patients and had taken action “to ensure there is no repeat”.
She added: “Patient safety remains the highest priority of the Scottish Government but unfortunately mistakes can happen, and where they do we expect health boards to act swiftly and ensure lessons are learnt to prevent incidents happening again”. She said thousands of safe operations take place every day, adding: “Scottish hospitals are among the safest in the world”.
Radical operational revamp
FOLLOWING the probe, theatres are set for a radical overhaul.
Around 1200 staff are to attend compulsory training in coming months.
Daily and weekly meetings between teams are to take place to improve patient safety. Chatting about anything other than operations during critical periods is to be banned under the new regime.
New rules around communication, in which staff must acknowledge being spoken to, will also be introduced. New pre-operative care plans will be developed across NHS Lothian. Restraints will be used when tilting operating tables.