Preventing a never

Source: NHE Sep/Oct 17

Maryanne Mariyaselvam, NHS Innovation Accelerator (NIA) Fellow at NHS England and clinical research Fellow at the University of Cambridge, and Peter Young, consultant in critical care at Queen Elizabeth Hospital in King’s Lynn, on a new device designed by frontline staff to prevent costly and serious Never Events.

The Royal College of Emergency Medicine (RCEM) circulated an alert in August indicating that 50% of Never Events in the emergency department are retained guidewires. Retained guidewires have an overall incidence of 1:3,291 procedures, and a reported mortality of 20%. 

Historically, prevention purely relied on checklists, two-person procedures, communication and ongoing training programmes, yet despite this the incidence in the NHS has risen. 

Reasons for the errors have been shown to be inattention, distraction, poor supervision, inexperience, high workload, and fatigue – all commonly seen in hard-pressed frontline clinical specialties. Sadly, humans are fallible and solutions that rely on operator memory to prevent mistakes both increase cognitive load and are unlikely to be fully effective. 

The transport and energy industry routinely uses safety engineering to modify its equipment and design errors out of the system. A similar approach has now been used in healthcare to engineer a solution to this Never Event. Training programmes are laudable but fallible and costly, and must be regularly repeated to maintain efficacy. In the real world, checklists often fail in stressful and time-pressured situations despite best intentions. 

The WireSafe 

A new device has been designed by frontline NHS clinicians as an engineered solution to prevent this Never Event, and it has been competitively selected for the NIA programme, supported by NHS England and the Academic Health Science Networks, to support widespread adoption. It has already received a National Patient Safety Award commendation and a President’s Award from the Royal College of Anaesthetists. 

The WireSafe is simply a locked pack within the sterile procedure pack containing the equipment required for completing the procedure after the guidewire should have been removed (e.g. suture, suture holder, dressings). The guidewire is used as a key to unlock the pack and access the contents enforcing guidewire removal at this critical step. Using human factors principles, a forcing function has been designed into the procedure which prevents the clinician from completing the procedure unless they first remove the guidewire. 

The WireSafe has been shown to be effective to prevent retained guidewires in a randomised controlled trial published in Anesthesiology, and was found to be acceptable to clinicians for improving patient safety. It has now been used in both central venous catheterisation across the UK and, more recently, in chest drain wired procedures. The WireSafe also facilitates safer suturing and safe clear-up of sharps at the conclusion of the procedure, protecting clinicians from needle stick injuries. 

Currently following a retained guidewire frequently frontline staff carry a personal responsibility, creating a second victim. Arguably now a solution exists; this responsibility is shifted in the direction of an institution as a systems problem. The WireSafe supports the checklist suggested by the RCEM, protecting patients, staff and institutions from this unacceptable error.





There are no comments. Why not be the first?

Add your comment


national health executive tv

more videos >

latest healthcare news

Winter pressures mounting as A&E attendances creep up by 4.4%

14/12/2017Winter pressures mounting as A&E attendances creep up by 4.4%

NHS England’s latest figures show that although the health service is responding well to growing pressure, it is close to “full stretch... more >
Kent trust appoints NHSI director as new chief executive

14/12/2017Kent trust appoints NHSI director as new chief executive

Maidstone and Tunbridge Wells (MTW) NHS Trust has appointed Miles Scott as its new chief executive. Scott joins the trust from his position ... more >
CCGs must move towards strategic commissioning to improve local care

14/12/2017CCGs must move towards strategic commissioning to improve local care

CCGs in the UK should move towards strategic commissioning if the healthcare system is to embrace a move toward integrated local care, claims a n... more >
681 149x260 NHE Subscribe button

the scalpel's daily blog

Ten lessons to support new care models locally

29/11/2017Ten lessons to support new care models locally

Anna Starling, policy fellow at the Health Foundation, offers the top 10 lessons for local leaders seeking to make systematic improvements across services, all based on first-hand accounts from vanguard officials. Redesigning health and social care services across traditional boundaries is not easy. Making change in complex environments, with differing professional viewpoints and varying organisational priorities while getting on with t... more >
read more blog posts from 'the scalpel' >


Cutting through the fake news

22/11/2017Cutting through the fake news

In an era of so-called ‘fake news’ growing alongside a renewed focus on reducing stigma around mental health, Paul Farmer, chief exec... more >
Tackling infection prevention locally

04/10/2017Tackling infection prevention locally

Dr Emma Burnett, a lecturer and researcher in infection prevention at the University of Dundee’s School of Nursing and Midwifery and a boar... more >
Scan4Safety: benefits across the whole supply chain

02/10/2017Scan4Safety: benefits across the whole supply chain

NHE interviews Gillian Fox, head of eProcurement (Scan4Safety) programme at NHS Supply Chain. How has the Scan4Safety initiative evolved sin... more >
Simon Stevens: A hunger for innovation

25/09/2017Simon Stevens: A hunger for innovation

Simon Stevens, chief executive of NHS England, knows that the health service is already a world leader when it comes to medical advances – ... more >

last word

The Refugee Doctor Initiative

The Refugee Doctor Initiative

Terry John, co-chair of the BMA & BDA Refugee Doctors and Dentists Liaison Group and chair of the union’s international committee, talks about a brilliant initiative that is proving mut... more > more last word articles >

editor's comment

25/09/2017A hotbed of innovation

This edition of NHE comes hot on the heels of this year’s NHS Expo which, once again, proved to be a huge success at Manchester Central. A number of announcements were made during the event, with the health secretary naming the second wave of NHS digital pioneers, or ‘fast followers’, which follow the initial global digital e... read more >

health service focus

Release full market value against surplus and decommissioned assets

28/11/2017Release full market value against surplus and decommissioned assets

Advertisement feature: Oliver Pearson, sal... more >
Operation Barcode: selecting technology to succeed

22/11/2017Operation Barcode: selecting technology to succeed

The benefits of Scan4Safety have been widely ... more >