The Care Quality Commission (CQC) has today reported that surgical teams at the Royal Cornwall Hospital have made the safety improvements which were required in its operating theatres.
Inspectors found that important checklists recommended by the World Health Organisation (WHO) and the National Patient Safety Agency (NPSA) are now being effectively used in the operating theatres at the hospital in Truro.
The unannounced inspection followed concerns which were raised earlier in the year when the Royal Cornwall Hospitals Trust reported its fifth 'Never Event' in its operating theatres within 18 months. Never events are serious, largely preventable incidents which should not happen.
Following that incident, CQC inspectors, accompanied by a professional clinical advisor, visited eight operating theatres in May to watch procedures and speak to clinical staff.
Immediately after that inspection the trust was told it must make urgent improvements, or face possible enforcement action.
The inspection team found that the surgical safety checklist, which aims to improve the safety of surgery, reducing deaths and complications, was not being applied properly or consistently. The checklist consists of a system of safety checks which are carried out at various stages of a patient's progress through an operation.
Inspectors also found that:
- patients were at risk of receiving inappropriate treatment because information about their operation was inconsistently recorded.
- some equipment was in need of repair or replacement as areas where tape or gloves had been used to repair or improvise could increase the risk of infection or pressure area damage for patients.
- there were not always enough skilled staff on duty.
- the hospital's internal systems for assessing and monitoring the quality of service were not good enough, and a culture of reacting to problems rather than monitoring and preventing them, meant that some patients were at an increased risk of receiving unsafe care and treatment.
Royal Cornwall Hospitals Trust responded by introducing a standardised surgical safety checklist written by the WHO and recommended by the NPSA.
On 14 July, the inspection team returned to the hospital to check that the required improvements had been made, and to observe 12 operations.
This time they found that surgical safety checks were being carried out in a satisfactory and consistent way. Staff said that since undergoing training on how to use the full checklist they felt more confident, and better placed to challenge and ask questions.
Unsuitable or damaged equipment had been replaced, the trust had also developed improved systems to monitor the quality of its services and brought in an external consultant to review practice in all its theatres.
Amanda Sherlock, CQC Director of Operations, said that there had been a significant improvement to patient safety.
"On our first inspection we saw numerous examples where surgical safety checks were not being carried out properly within the operating theatres. It is critical that these key checks are completed without exception; failure to do them properly increases the risk to patient safety.
"As an example, we noticed that the way swabs were collected and counted varied between operating theatres. This puts people at risk because staff who move from one theatre to another will be unfamiliar with each system and so are more likely to make mistakes.
“Our latest inspection told a completely different story. The trust has now introduced the standardised surgical safety checklist across all its theatres and we saw 12 examples where the surgical safety checks were being carried out in a satisfactory and consistent way. All 12 ‘sign in’, ‘time out’ and ‘sign out’ checks were carried out using a formal process, and they were clear and comprehensive.
“Staff told us that introduction of the checklist and the associated training programme had meant a real change which has added important value. Staff we spoke to were now aware of the never events that led to these changes being put in place and understood there had been a theatre safety issue.
“I am satisfied that the improvements in education, consistency of approach and communication has created an environment where patient safety is much improved and where best practice can develop."
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