Select Committee on Health Written Evidence


Memorandum by the Royal College of Surgeons of England (PS 69)

PATIENT SAFETY

  1.  The Royal College of Surgeons welcomes the opportunity to contribute to the Health Select Committee's inquiry into patient safety. Patient safety is implicit in all the College does and stands for. We believe that patients and surgeons alike require the best available information on which to base decisions as well as having effective systems in place to bring together information on patient safety. Surgeons must be able to communicate about potential problems as quickly and effectively as possible. The College is committed to improving patient safety in all aspects of surgery from current practice to new and emerging techniques.

SURGERY, RISK AND PATIENT SAFETY

  2.  In the early part of the 20th century patient safety in surgery was almost entirely concerned with mortality rates from an operation and rarely about the quality of life after an operation. However improvements from technical and scientific advancements in surgery and progress in anaesthesia mean that today death rates for the majority of surgical procedures are very low. In the 21st century patient safety is reflected more broadly in a range of outcomes from surgery such as complications, quality of life after an operation and readmission rates against the risk of not having the procedure or an alternative treatment if one exists. Patients and surgeons are increasingly involved in measuring outcomes and patient safety incidents as well as directly accessing information about their care.

  3.  In surgery there is always an element of risk from the procedure which can be managed but never completely eliminated. In many cases the risk has to be understood over the long term as in the short term the risk from the procedure may be greater than having no treatment. Risk can be communicated in general terms but ultimately needs to be specific individualised to patients, each of whom may have a different attitude to the level of risk they deem acceptable.

  4.  Surgeons have a duty of care to explain the levels of risk and reduce the risks where they arise. As part of our "Good surgical practice" publication[366] the College sets out standards for managing professional relationships with patients. Part of this guidance is to allow sufficient time to provide information about the treatment including the alternatives, main risks, and possible side effects and complications. Surgeons are often able to explain the risks associated with the procedure but are very often unable to explain the wider risks of the hospital environment such as healthcare acquired infections, access to medication and follow-up care which may significantly affect the outcome.

  5.  Ultimately the patient is responsible for the final decision about the level of risk they find acceptable based on the information they have. The patient, supported by the surgeon, chooses whether to proceed with the surgical procedure or other courses of treatment if available. For the patient to have all the information they require about the specific and general risks of the procedure is extremely difficult given the variety of sources required to make a clear assessment. The College encourages the audit of services and publication of the outcomes to help patients understand the risk. Government needs to support the collection of data and its analysis.

PATIENT SAFETY ISSUES IN SURGERY

  6.  In surgery there are several preventable issues that affect patient safety such as wrong site surgery, retained swabs and missing and dirty surgical instruments recently highlighted by the NPSA. Surgeons are aware of the issues which are not new but systems are needed to increase awareness. These incidents are rare when compared against the 8 million or so surgical procedures that take place in England every year but are potentially life-threatening when they do occur.

  7.  The National Patient Safety Agency (NPSA) through the National Reporting and Learning System (NRLS) collects information on patient safety incidents, including surgery, from all Trusts in England. This information is analysed and fed back to the Trusts giving a high-level profile of reported incidents. Given that the NPSA has collected over 2 million patient safety incidents since it was established in 2003 we believe that the Agency should be funded to develop its role in providing a more detailed analysis of patient safety incidents to surgeons and other healthcare professionals as well as information that can be directly accessed by the public and that can be linked into other websites such as NHS Choices. For example, a search of the patient safety information database, which contains all alerts, directives, tools and guidance issued by the NRLS, using the keyword surgery only produces one result which was advice on correct site surgery in 2005 produced jointly with the College.

  8.  Access by individual surgeons to data reported by patients, surgeons and other healthcare professionals throughout their careers would also allow incidents that have been reported by colleagues in similar areas of practice to be flagged up and implications for their own work considered. There also maybe a function for surgeons to share potential solutions and best practice in response to reported incidents.

  9.  We are aware for example of incidents associated with wrong site surgery and missing, dirty and broken surgical instruments but these do no appear as part of the NRLS analysis. The quarterly reports the NRLS produces are useful in identifying overall trends in reporting and the broad categorisation of these incidents but for surgeons working in hospitals there is no indication of the type of incidents being reported and how they benchmark with similar units in England. As far as we are aware the data collected is sufficiently detailed to allow such analysis. The NRLS also has a potentially valuable role in making information available to the public, an aspect of their role they haven't so far exploited.

ROLE OF THE COLLEGE AND SURGEONS

  10.  The College is leading the publication of outcome data and together with the Society of Cardiothoracic Surgeons has pioneered the collection and use of both surgeon and patient reported outcome measures.[367] The College has just embarked on a major project studying patient reported outcomes for five common operations in every independent sector treatment centre and a sample of NHS hospitals in the country. More than 500,000 patients a year will be covered by this study and, with the first data starting to come in, early results will be published at the end of 2008. The College would welcome the development of the linking of patient safety indicators, collected by the NPSA, into the outcome data that are starting to be developed by the College and the speciality surgical associations.

  11.  On an international level the College supports World Health Organization's Safe Surgery initiative and the surgical safety checklist as a way to define a set of core safety standard that can be applied in all WHO member states. The College has been active in exploring checklists at the national level which was one of the recommendations of the advice on correct site surgery produced with the NPSA. As well as recommendations for surgical teams an information sheet for patients about to have surgery was produced explaining the purpose of marking the site of surgery and what should be expected during the pre-surgery procedures.

  12.  The College also issues guidance on broader issues of patient safety but that clearly affect surgery. For example we have recently developed a policy on healthcare acquired infections and the implications for surgeons and the public. We have also produced a College briefing on trauma care focussing on the requirement for specialist hospitals providing this care as part of a network across England.[368] We have recommended criteria for the location of trauma centres which we believe will deliver the best clinical care, improve patient outcomes and ultimately provide a safer service for patients.

  13.  Individual surgeons have a responsibility to uphold best practice across the scope of their work. The College believes that surgeons have a responsibility to report to their employer, in a confidential system, incidents that compromise patient safety. The surgical team should also be required to report incidents in a similar manner. It is the responsibility of the employer supported by the national data collected by the NPSA to monitor incidents and provide constructive feedback and training if required.

CURRENT COLLEGE ACTIVITIES

  14.  Effective communication is at the centre of improving patient safety in surgery. The College also recognises the important role that leadership and good team working plays in the performance of clinical teams and the resulting positive outcomes for patient safety.[369] The College is working with surgeons not only to improve their communications with patients but to improve communications between surgeons and within the wider surgical team. The College has developed and has been running for a number of years a training course entitled "Safety and Leadership for Interventional Procedures and Surgery (SLIPS)". The course is designed to teach all members of the surgical theatre team how to improve communication and develop leadership in teams. It also looks at how to reduce the risk of medical errors by introducing theory and research evidence, and creating an understanding of human factors in improving patient safety.

  15.  The significant reduction in working hours with the introduction of the European Working Time Directive (EWTD) will have an impact on service delivery and training and potentially patient safety. We are collaborating with the Royal College of Anaesthetists on a joint project to examine the current level of compliance with the 2009 Working Time Directive for a 48 hour working week so that we can share learning and good practice amongst trusts, surgeons and anaesthetists. As part of this project, we are working to provide rota planning software to surgeons to ensure that they have the knowledge and skills to design rotas which protect patient safety, minimise disruption to training and provide the best levels of continuity of care.

  16.  Recertification and revalidation promoted by the Department of Health will require all doctors to demonstrate to the General Medical Council that they are up-to-date and fit to practise medicine is an ideal opportunity to bring patient safety records into the measurement of patient outcomes. We would welcome an expansion of the NPSA's resources to allow them to undertake more detailed analysis of the data on surgical incidents they already collect so that surgeons and their trust managers can examine incidents at the unit level and ideally at the individual level.

  17.  Apart from incidents around the individual surgeon and the surgical team the College is also concerned about the patient safety incidents attributable to medical devices already in routine use and new devices coming on to the market. There are also patient safety risks around decontamination of instruments that can also affect outcomes. We believe that a number of patient incidents go unreported because systems are not in place to either easily collect the information directly in the case of reports from patients or analyse incidents that are collected by the NPSA to allow feedback on emerging trends at the earliest opportunity. The College is supporting the Confidential Reporting System in Surgery (CORESS) initiative which analyses safety-related incidents reported to the organisation and provides feedback via quarterly reports. Although run for general surgeons it can provide potential solutions and useful indicators to best practice which affect patient safety.

  18.  The safe and rapid introduction of new techniques in surgery is important if they quickly improve existing procedures or provide new treatments. This is an area of interest for the College which we believe will improve patient safety by improving outcomes from treatments. Clinical trials undertaken to ensure safety and benefit to patients are the mainstay of any evidence based assessment and should continue to be. If proven effective, the introduction of these new techniques needs to be followed by training to ensure they are delivered safely and for the maximum benefit of patients. The College believes that innovation, if implemented carefully, will deliver improvement in patient safety and long-term outcomes.

  All references are available from http://www.rcseng.ac.uk/publications/docs

September 2008








366   Good Surgical Practice (Royal College of Surgeons, 2008). Back

367   Measuring and using outcomes from surgery (Royal College of Surgeons, 2008). Back

368   Provision of trauma care: policy briefing (Royal College of Surgeons, 2007). Back

369   Leadership and management of surgical teams (Royal College of Surgeons, 2007). Back


 
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