National Patient Safety Agency
Released on - 09/08/2010
National Patient Safety Agency-Clinical Board for Surgical Safety
Achievements in the first two years
The Clinical Board for Surgical Safety was established in October 2008 in response to a recommendation in the 2007 Annual Report of the Chief Medical Officer to provide advice and oversight to the National Patient Safety Agency ( NPSA’s) collaborative work programme in surgery. The Board is chaired by President of Royal College of Surgeons and membership includes representation from all relevant Colleges and Associations.
Key priorities for the Board have included
• Setting the strategic direction and priorities for patient safety in surgery and providing high level leadership.
• Facilitating a more collaborative and coordinated approach in delivering the patient safety agenda at a national level.
• Offering advice about design and implementation of solutions as new patient safety issues in surgery are identified.
• Advise on most appropriate methods of communication and dissemination of initiatives and best practice and encourage stakeholder engagement.
• Maintaining oversight of existing national and international initiatives and current programmes of work that impact on surgical safety in NHS funded care.
Key Achievements
The Board has advised at developmental stages and provided ultimate endorsement to the NPSA Rapid Response Reports
• Avoiding wrong side burr holes-craniotomy
• Mitigating surgical risk in patients undergoing hip arthroplasty for fractures of the proximal femur
• Minimising risks of suprapubic catheter insertion
• Reducing the risk of tourniquets left on after finger and toe surgery
• Checking pregnancy before surgery
• Failure to recognise deterioration of patients following laparoscopic surgery (still in draft format)
Emerging issues from NPSA National Reporting and Learning System (NRLS) data discussed at the Board which have resulted in the production of articles for NPSA ‘Signals’ and the British Medical Journal include:
• Digital transfer of neurological imaging – this also resulted in a letter from the Board to Department of Health
• Use of injectable medicines in the theatre environment
• Torsion of the testicle
• Missed compartment syndrome
At the last meeting it was agreed that the issue of wrong site dentistry should be progressed through the development of a Rapid Response Report.
The Board have been closely involved in the implementation of the WHO surgical safety Checklist and advised on initial urgent amendments to the NPSA Alert following concerns expressed at the European Summit on Safer Surgery in January 2009. Since then regular progress reports on implementation have been received from Patient Safety First Campaign, 1000 Lives Campaign and NPSA. More recently the Imperial Evaluation Programme provides regular progress reports to the Board.
Over the last two years the reputation of the Board and the benefits of bringing the professional organisations together has spread resulting in additional membership and the establishment of NPSA Safety Boards for Medication, Medical Specialities and Children.
