Preventing a never event

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.





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