Queen Elizabeth King’s Lynn NHS Trust and King’s Lynn Institute of Patient Safety

A human factors’ approach to engineering our serious adverse events and Never Events - WireSafe and non-injectable connector initiatives.

What the judges said:

What was particularly impressive regarding the submission from Queen Elizabeth King’s Lynn NHS Trust and King’s Lynn Institute , was how the human factor(s) of ‘design’ was actively acknowledged and addressed (rather than a system issue), and how the tenacity and leadership of the team to overcome the barriers of change management and culture, funding and procurement has finally come to fruition and influenced national learning.

There are two persistent sources of patient harm commonly seen in operating theatres and intensive care units involving arterial and central venous catheters, which are arterial misinjection and guidewire retention. These problems have proven stubbornly resistant to solutions aimed at improving individual clinician performance, such as checklists and training. By adopting a human factors approach, however, the team at Kings Lynn seem to have found a way to engineer new solutions to these problems, making the prospect of patient harm from these two causes almost impossible.

Arterial catheters are used to very accurately measure the patient’s blood pressure on a second by second basis, and to take blood samples. Central venous catheters are used to monitor venous blood pressure, administer strong medication and haemodialysis. During central venous catheter insertion, the catheter is preceded by a much smaller wire, called a guide wire, which the doctor uses to set out the ‘route’ to the heart and is then removed as the catheter is thread over it.

Thousands of these procedures happen safely every day. But, in a very few cases, problems can occur. Arterial misinjection, where fluid is injected incorrectly administered into this catheter, or guidewire retention where the procedure is completed without the guide wire being removed. Both can cause serious harm.

Despite such investigations, changes to training, alerts and warnings, these risks have persisted everywhere this procedure is conducted. After witnessing and analysing these events, Peter Young and Maryanne Mariyaselvam decided a different approach was needed.

Human factors analysis of the context around such incidents showed that the cognitive demands and dynamic nature of the task meant that training and warnings would never eliminate the possibility of error. So they sought to design these possibilities out, instead.

They designed a noninjectable arterial connector that has a one-way valve in it, which simply closes and prevents an arterial misinjection if the clinician accidentally tries to do so. They also designed WireSafe, a box of equipment for catheterization that prevents the clinician moving to the next step if the guide wire has not been removed. Mechanically, these are relatively simple ideas, but their effect is profound. They effectively eliminate the possibility of the errors that were causing these problems before.

As a change in clinical practice, the biggest challenge has been less about the design of the solution, and more about encouraging adoption and take-up. Clinicians naturally can be wary of changing clinical practice, especially if they have not had personal experience of these problems. In such cases, Peter and Maryanne have driven adoption through personal discussion, publishing in the literature and by asking more senior clinicians to act as role models for more junior doctors.

A less tangible barrier has been the reluctance of management committees to adopt new practice. Managers can be reluctant to approve practice innovations in case they go wrong or cost too much. Peter and Maryanne’s innovations have been selected onto the NHS Innovation Accelerator Programme, addressing cost and policy issues, and reducing the hurdles required to secure management approval.

Even so, it is has not been an easy or rapid path. But as a result of their persistence, creativity and sheer determination over many years, their two innovations - the NIC noninjectable arterial connector and WireSafe - are now used across the NHS and they are seeing increasing adoption.

This is an exciting project, but it has not been an easy one. We were struck by the team’s innovative use of human factors to help design an alternative way of thinking about solutions to these problems and create new solutions. We were taken also by the elegance and simplicity of their solutions; the elegance and simplicity that results only from hard thinking, rigorous testing and clever design. And we have learned that even when a solution is clearly practical, simple and cost-effective, driving adoption by both clinicians and with management requires persistence, patience and sustained effort over time. And the results are worth it.

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