Rob Tomlinson, Dr Mike Pollard and team – East Lancashire Hospitals NHS Trust

Never Event Presentation (a systems approach) and 10,000 Feet

What the judges said:

"Challenging culture and practice within specialities where errors in care occur needs to adopt both a sensitive but pragmatic and credible evidence-based approach. The submission from East Lancashire Hospitals NHS Trust demonstrates how using such evidence and practice from the airline industry can be aligned in the surgical environment of the operating theatre to empower staff at all levels to address some of the human factors that have the potential to contribute to human error and harm."

In many trusts, a small proportion of procedures lead to patient harm because of what has been referred to as a clinical error. Such instances include, for example, when a swab is retained in a patient’s body after surgery. Historically, such incidents have been followed by a search for blame, further training and the imposition of sanctions on individuals. Despite such efforts, and other activities, such as communications and checklists, such ‘never events’ seemed still to happen.

An operating theatre can be a noisy environment, peopled by a range of clinical staff. Surgeons may discuss strategies for proceeding when they uncover something unexpected; an anaesthetist may flag up a trend in a patient’s blood gases; a scrub nurse may have to count out loud the number of swabs used in an operation to confirm that all have been removed before a patient is closed up; other nurses may be typing on a laptop to record drug administration. Some surgeons may like to have music playing. Instrument trays can be moved noisily while other nurses may be asked to fetch additional dressings. And sometimes people are just talking. Most of the time, such an environment works well – people find it stimulating and discussion happens as required.

East Lancashire Trust had a cluster of ‘never events’ and investigated them using the principles of ‘just culture’ – seeking causes, rather than blame. Rob Tomlinson, a scrub nurse, was motivated by his experience of a never event and this form of investigation to examine why such events continued to happen. He used a systems approach to analyse the events and identify causes, and created a presentation that showed that, in some circumstances, noise and distraction interfered with certain tasks, such as when a scrub nurse had to tally and reconcile the number of swabs recovered with the number used. At the same time, however, the social hierarchy of theatre meant that more junior clinical staff sometimes felt unable to ask for quiet when they needed it.

Rob came across an idea put forward by John Gibbs and Pete Smith, Clinical Nurse Specialists in Australia. They used an idea borrowed from aviation, called ‘Below 10,000 feet’. Pilots flying a commercial jet will typically have a relaxed attitude and conversation when cruising at altitude. But when a plane descends below ten thousand feet, this triggers a requirement that all non-essential conversation ends. This allows flight crew to concentrate on their key tasks quickly and accurately to help land the aircraft.

Gibbs and Smith propose using the same idea in an operating theatre. At any time, anyone working in the theatre who needs to focus their attention at a task in hand can call “10,000 feet”. This ‘safe word’ is a signal for everyone in the theatre to stop any but essential conversation. It can be called by anyone, regardless of their place in the hierarchy in the theatre.

Tomlinson worked with his team and with Dr Mike Pollard, with the backing of the medical director, started to introduce this idea into operating theatres. They trained people, designed posters, created communications and established a sustained programme of messaging and support for the idea that anyone can call “10,000 feet” at any time in theatre when they need to focus.

It's a simple idea, but the effect is profound. Everyone stops their conversation and focuses directly on the immediate tasks in hand. People trust that it was called for good reason and with professional intent, and so they give their colleagues the time and quiet that they need.

An unexpected side-effect has been an increase in team working, as the use of ‘10,000 feet’ disregards hierarchy. To date, 75% of ’10,000 feet’ calls have been made by more junior staff. The call has been made at every critical stage of the patient pathway: intubation, extubation, WHO checklist, scrub counts and other crucial points during a patient’s care in theatre.

As 50% of calls have been made at the point of running through the WHO safety checklist, it is clear that this procedure is actively contributing to patient safety. But it has also been called by a student nurse to ensure the full team complete the WHO checklist sign-out and by anaesthetic nurses in recovery to help a new mother hear the midwife’s instructions on breastfeeding her new-born. Such instances show that this protocol is helping reduce the potentially negative effect of medical hierarchy to deliver better, safer patient care.

Use of ‘10,000 feet’ directly addresses the causes of at least two of the never events that triggered this initiative. It has improved team-working, allowed focus at key points for safety and enabled theatre teams to work together more effectively. A paper on its use has been accepted by the Journal of Perioperative Practice and has prompted interest from other trusts and from the Department of Health. And, what is more, its only cost is the time and attention needed to communicate and sustain the idea while it is being adopted. It’s simple, practical, cost-effective and actively contributes to patient safety: no wonder our judges liked it.

Update from Rob Tomlinson (April 2019):

The 10,000 Feet concept is embedded and part of the ‘DNA’ of operating theatres at East Lancashire. We continue to use the concept and have built quite a story on this patient centred safety concept. It has been recognised by the Association for Perioperative Practice who are hoping to produce evidence to prove that, like in the aviation industry, this improves patient safety. The Care Quality Commission recently published a small case study on 10,000 Feet on page 17 of this publication. The Care Quality Commission also identified 10,000 Feet as 'outstanding practice' in our recent inspection. In the short term at East Lancashire, we are hoping to introduce the concept across the Trust to other areas, including endoscopy, radiology, angiography and midwifery.

Myself and Dr Mike Pollard continue to deliver the Never Event presentation far and wide. We are sharing the learning from our never events but also sharing with other hospital trusts how the just culture we have in place has allowed us to strengthen safety systems to protect our patients and prevent us from having further never events. In addition, we are sharing the 'below ten thousand' concept, which is capturing national attention.

The presentation continues to score highly from audience feedback and am now delivering it to these conferences –

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