In harm’s way
BMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l2037 (Published 08 May 2019) Cite this as: BMJ 2019;365:l2037All rapid responses
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Dear Sir,
The system of developing patient safety is ever evolving and the adoption of the WHO checklist has helped in reducing patient harm but as perioperative physicians we feel that there is a significant blindspot in our theatre systems.
One will be aware that a British Airways flight landed in Edinburgh in March 2019 instead of the destination being Dusseldorf as the flightpaperwork submitted were wrong and WDL Aviation ran the BA flight through a leasing deal.
If we are to deploy the simile in NHS, the consent for operations are still being completed by doctors ranging from the core trainee stage to the seniors in the outpatient clinic and on the day the surgeon operating may be a different surgeon than the one who decided or consented the patient.
The system to check the consent varies from hospital to hospital and could range from a theatre nurse checking the consent with or without an anaesthetist and then the patient goes under the anaesthetic- the issue here is, although it might match the paperwork ie the theatre list or the site, the pilot (the surgeon) is the right person who actually knows what procedure is going to take place instead of what has been listed and should be involved in the final check with the patient before the anaesthetic has been delivered. The triangulation of the consent from the patient, with the surgeon’s understanding of the operation needed and the theatre list, will tighten the safety system of checking before the flight has begun for each patient and we would suggest that the “pilot on the flight” does the final check before the take off.
We would like to highlight this blindspot in preop patient checks and hopefully influence a change in the system.
Yours sincerely
Dr Bhaskar Saha
Dr K Mohamed Hassan
Competing interests: No competing interests
Re: In harm’s way
The key going forward is 'collective action' and reaching agreement about what action to take. This is the hardest question as with so many voices in healthcare we could all be going in different directions. Small steps are best, and reading around a subject is a good starting point. 'Avoiding Errors in General Practice' by Barraclough et al 2013 is a good addition to any reading list on patient safety and an excellent companion to reflection at both individual and systems level.
Competing interests: No competing interests