Northern Health and Social Care Trust, Antrim, UK.
Royal London Hospital, London, UK.
Int J Risk Saf Med. 2023;34(3):189-206. doi: 10.3233/JRS-220055.
Never Events represent a serious problem with a high burden on healthcare providers' facilities. Despite introducing various safety checklists and precautions, many Never Events are reported yearly.
This survey aims to assess awareness and compliance with the safety standards and obtain recommendations from the National Health Service (NHS) staff on preventative measures.
An online survey of 45 questions has been conducted directed at NHS staff involved in invasive procedures. The questions were designed to assess the level of awareness, training and education delivered to the staff on patient safety. Moreover, we designed a set of focused questions to assess compliance with the National Safety Standards for Invasive Procedures (NatSSIPs) guidance. Open questions were added to encourage the staff to give practical recommendations on tackling and preventing these incidents. Invitations were sent through social media, and the survey was kept live from 20/11/2021 to 23/04/2022.
Out of 700 invitations sent, 75 completed the survey (10.7%). 96% and 94.67% were familiar with the terms Never Events and near-miss, respectively. However, 52% and 36.49% were aware of National and Local Safety Standards for Invasive procedures (NatSSIPs-LocSSIPs), respectively. 28 (37.33%) had training on preventing medical errors. 48 (64%) believe that training on safety checklists should be delivered during undergraduate education. Fourteen (18.67%) had experiences when the checklists failed to prevent medical errors. 53 (70.67%) have seen the operating list or the consent forms containing abbreviations. Thirty-three (44%) have a failed counting reconciliation algorithm. NHS staff emphasised the importance of multi-level checks, utilisation of specific checklists, patient involvement in the safety checks, adequate staffing, avoidance of staff change in the middle of a procedure and change of list order, and investment in training and education on patient safety.
This survey showed a low awareness of some of the principal patient safety aspects and poor compliance with NatSSIPs recommendations. Checklists fail on some occasions to prevent medical errors. Process redesign creating a safe environment, and enhancing a safety culture could be the key. The study presented the recommendations of the staff on preventative measures.
“永不事件”是医疗保健提供者设施面临的严重问题，具有较高负担。尽管引入了各种安全清单和预防措施，但每年仍有许多“永不事件”发生。
本调查旨在评估 NHS 员工对安全标准的认知和遵守情况，并就预防措施征求 NHS 员工的建议。
对参与侵入性程序的 NHS 员工进行了一项 45 个问题的在线调查。这些问题旨在评估向员工提供的患者安全意识、培训和教育水平。此外，我们设计了一套重点问题，以评估对国家安全标准（NatSSIPs）指南的遵守情况。还添加了开放性问题，以鼓励员工就解决和预防这些事件提供实际建议。通过社交媒体发送邀请，调查从 2021 年 11 月 20 日至 2022 年 4 月 23 日保持开放状态。
在发出的 700 份邀请中，有 75 人完成了调查（10.7%）。分别有 96%和 94.67%的人熟悉“永不事件”和“险些事件”这两个术语。然而，分别有 52%和 36.49%的人熟悉国家和地方侵入性程序安全标准（NatSSIPs-LocSSIPs）。28 人（37.33%）接受过预防医疗差错的培训。48 人（64%）认为应该在本科教育期间提供安全清单培训。14 人（18.67%）在清单未预防医疗差错时经历过。53 人（70.67%）看到过包含缩写的手术清单或同意书。33 人（44%）的计数核对算法失败。NHS 员工强调了多层次检查、使用特定清单、患者参与安全检查、充足的人员配置、避免在手术中途更换人员以及改变清单顺序的重要性，还强调了在患者安全培训方面的投资。
本调查显示，一些主要的患者安全方面的认知度较低，并且对 NatSSIPs 建议的遵守情况较差。清单有时未能预防医疗差错。创建安全环境的流程设计变更和增强安全文化可能是关键。该研究提出了员工对预防措施的建议。
