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Newcastle Hospital - Mouse Mat to promote patient safety and prevent “Never Events"

Released on - 02/03/2021

Newcastle Hospital - Mouse Mat to promote patient safety and prevent “Never Events

Thanks to NuTH Theatres at Newcastle Hospital for sharing measures they've put in place to promote patient safety & prevent “Never Events.” Education, training, improved communication & posters have all helped create a positive culture. 

They’ve also developed a 10 Always Events mouse mat. It promotes the high quality care messages that keep patients & staff safe & assist in prevention of Never Events, & celebrates the best practice that ensures a high quality perioperative patient experience.

Below is their submission. 

Team: NuTH Theatres Newcastle Hospitals NHS Foundation Trust 

Project: Mouse Mat to promote patient safety and prevent “Never Events.”

10 Always Events to Enhance the Perioperative Patient Experience 

Newcastle upon Tyne Hospitals NHS Foundation Trust has been providing patient centred healthcare to the communities of the North East for over 250 years and is one of the most successful teaching NHS Trusts in the country. 

The Trust comprises of over 1,800 beds, over 1, million patient engagements every year and currently employs approximately 14,000 staff. NuTH Theatres currently employs over 850 staff and comprises of 53 Operating Theatres. Patient safety and the delivery of high quality patient care is   a key priority for all of the staff working in the theatre teams.

In 2013 four Never Events occurred across NuTH theatres sparking a significant investigation, review of practice, lessons learned and change of culture. Moving forward it was imperative to ensure that key patient safety messages remained at the forefront of all staff practice and patient centred care delivery. The introduction changes and developments over time has embedded a blame free culture for safe supported working which ensures that patient safety is always at the centre of everything we do.

There has been a significant collaborative review of practice across all of the theatre disciplines exploring the Count Procedure process with policy development, annual audit framework, re-audit and escalation of the lessons learned.  Education and training in relation to human factors has been key and fundamental in staff training and development. Also communication pathways across all teams have been further enhanced with introduction of the team safety briefings where the promotion of key safety information discussed at each MDT WHO team meetings each morning.

 The introduction of quarterly Theatre Safety posters to promote and communicate trends from incident reports, along with key safety messages made it easy for all staff to access this safety information. Moving forward we have worked collaboratively to promote and ensure a positive culture of openness, reflection and constant learning for all members of the theatre team is which now well embedded into practice. 

To ensure the momentum in practice change is maintained we have developed a mouse mat to be introduced into all theatres and clinical areas in our theatres. The purpose of the 10 Always Events mouse mat is to promote all of the key patient safety messages for staff and act as a visual aid and constant reminder of the high quality care messages keeping our patients and staff safe every day and assist in the prevention of Never Events. This mouse mat also complies with Infection Prevention and Control requirements.

Seven years have now gone by since these Never Events occurred and a significant amount of measures have been put in place to ensure the delivery of high quality patient centred care to minimise the risk of Never Events.

This mouse mat also celebrates all of the best practice implemented by staff every day to ensure to ensure a high quality perioperative patient experience for all patients in our care.

At the beginning of this journey the theatre directorates worked independently during this time we have worked collaboratively together to share information, align practice and learning so that we can grow together for the benefit of the patient and all of the services delivered in NuTH theatres in the future.  We now deliver all of our training and education programmes together and this mouse mat is a celebration of our collaborative efforts over recent years.

We have been lucky to be given charitable support for the production of the mouse mats to enable us to place the message in all of the key and relevant areas in theatres and we are very grateful for this support. 

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