Rapid publication of serious incidences

Near-misses and adverse events should be published after anonymisation, on a national level. Anonymisation might not be possible in all instances, in which case, the lessons learnt from the case should be published.

Although the cost of AE may be great to the patient and the team, it is even greater if no lessons are learnt from it. These lessons learnt should be disseminated amongst all practitioners in that field. It is a disservice to the patient if the same errors happen again. Currently, publications by The National Patient Safety Association are infrequent, and the reporting of incidences of errors are published on a national scale. However, that is more useful for monitoring the culture of safety rather than of tangible use to clinicians in daily direct contact with patients. Weekly bulletins should be available to all NHS clinicians that inform them of

Timely central reporting

Using the NHS backbone, “Spine”, data-sharing of events, that currently take place over proprietary database inputs, should be set up.

The NHS, in theory, is a national institution. In reality, it is a disparate network of “trusts”, “health boards”, “clinical commisioning groups”, and a swarm of bodies and departments, separated in a lot of ways. This fragmentation greatly inhibits timely information-sharing and wears down any proclivity for doing so. The requirement for duplicating information entry into multiple systems is a waste of time, money, and human resources. The centralised collection of the data is then analysed by dedicated full-time teams that inform the concerned hospitals in frequent and timely manner. This is a system that not only allows for early and close-to-realtime detection of serious events, but also makes shares hospital’s best practices with the rest of the nation.

NHS Operations Research Unit

The centralised collection of national data should be analysed to produce real-time information on safety, efficiency and effectiveness, in addition to numerous other clinical and epidemiological data. The reason was aptly written back in 1962, less than a score after the conception of the NHS, by Prof. Henry Miller: “For effective research of this kind the centralized collection of data is not only the best but by far the most economical method of procedure. Failing this, such studies are left to individual investigators, under which circumstances they are indescribably laborious and expensive.” (Miller H. (1962) Operational Research in the N.H.S. BMJ 1(5284):1070) Now, there are many bodies that are already doing this, although in only very narrow remits, such as the NICOR (cardiovascular outcomes), UCL Clinical Operations Research Unit, and other such university units.

Surgical Air-Traffic Controller

We have seen many analogies comparing surgeons to pilots and the operating room to the aircraft flight deck. Extending this further, the Federal/Civial Aviation Authorities may be likened to the functions of the NPSA, and other organisations which appear to take on a reactive rather than a proactive approach. What is missing is the Surgical Air-traffic Controller. A group who has the wherewithal to see all the data in real-time across the surgical airspace, analyse and communicate with multiple teams to improve the safety and efficiency of the entire system.

Specialty Training in Statistics

Trainees should be trained to analyse their logbook cases and correlate their cases)to patient outcomes. This is feasible as patients are indexed by hospital ID in logbooks, and that can be linked to SCTS database records. This exercise should be undertaken by all trainees with appropriate mentorship and training in statistical analysis.

Surgical outcomes are now publicly attributed to individual surgeons and units. What started off as a crude figure of number of specific procedures and their mortality rates, is now developing into sophisticated analysis to incorporate the patient’s pre-morbid status, difficulty of the operation, volume-outcome correlations, peri-operative management and a host of other variables. This decades-old path that has been laid down by cardiac surgery (e.g. Blue Book, STS database) is still being led by the same specialty as other specialties are beginning to catch up, albeit secondary to considerable pressure. In this environment, it is vital that surgical trainees are given suitable training in the subtleties of the statistics behind these numbers, not only for practice improvement, but also for answering patient concerns. The current system appears to provide training by chance osmosis.