A for every 25 human beings alive. (2)

A critically reflective analysis of a work-based patient safety problem and the design of an evidence-based, targeted patient safety intervention. 


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Data from 56 countries showed that in 2004, the annual volume of major surgery was an estimated 187–281 million operations, or approximately one operation annually for every 25 human beings alive. (2)

Due to diversity within the case mix, it is difficult to compare death rates and complications following surgery, however, in industrialised countries the rate of major complications has been documented to occur in 3–22% of inpatient surgical procedures, and the death rate 0.4–0.8% (3,4). Nearly half the adverse events in these studies were determined to be preventable.

There is abundant evidence that failures in teamwork and communication contribute to these millions of adverse events. (5,6) An analysis of recordings of six complex operations found one communication failure every 8 min (7) and an observational study found communication failures in approximately 30 % of team exchanges, with a third of these resulting in effects that could threaten patient safety. (8)

The importance of effective communication in theatre is never more evident than in obstetric theatres. Obstetric emergencies can provide the perfect storm of on-call teams, junior staff, reduced staffing levels and support out of hours (OOH), high pressure, rapid clinical deterioration, and potentially life-threatening emergencies of a mother and an infant- often with an awake patient, and a birthing partner present in theatre.

It is my contention, backed by a recent Care Quality Commission (CQC) report (9) that communication in obstetric theatres at Hospital 1 is extremely variable, and that particularly out of hours, there is a paucity of communication which challenges patient safety.


Hospital 1 serves a population of approximately 165,000 (increasing significantly during the summer) it has 294 inpatient beds. In 2016/17 the trust treated 28,122 inpatients, and delivered 1,548 babies. The main hospital site provides a full range of acute services,

including an emergency department, critical care, end of life care, general medicine, maternity, cancer services, outpatients, and children and young people.

There are 5 main theatres, 2 day surgery theatres, 1 obstetric theatre, and an eye theatre.

The focus of this paper will be the maternity department.

The quality of obstetric care delivered at Hospital 1 has deteriorated since the last CQC inspection in 2014.  The October 2017 inspection stated maternity as requiring improvement, having previously been rated good. ‘Safe and effective care’ within the department was found to have worsened and was rated as requiring improvement. ‘Well-led care’ stayed the same and was rated requiring improvement.

The CQC found there was poor multidisciplinary working between the consultant obstetricians and midwifes, and that these challenging relationships did not promote safe care and effective working within the maternity unit.

The trust had four serious incidents in maternity in a five-month period, which identified failings in the assessment and prompt response by healthcare professionals which caused death or significant harm.

Following these events, the maternity service at Hospital 1 is in disarray and the consultant workforce is extremely unstable. Many consultants have been restricted from their labour ward obstetric practice (limited to gynaecological procedures only) and in the meantime these posts (85%) are being filled by locum consultants, which brings its own challenges.

I sought the opinions of those working within the department over the past number of weeks and can provide these observations:

The department lacks senior trainees in obstetrics, and the middle grade rota is staffed by permanent/locum middle grades in non-training posts. Most of these doctors were trained overseas, and have the additional challenge of practicing medicine in a foreign language. It is my observation that aside from one middle grade doctor, the majority are disinclined to reflect on the recent issues within the department. They are content with their own performance, and see the problems we face as being caused by the midwives.

The junior rota is largely covered by GP trainees, who have little interest or commitment to service development; as they struggle to gain supervision and training to fulfil their educational requirements within the post due to the upstream staffing crisis. Due to the length of their rotation (6 months) there is a sense of just trying to cope, to endure it, and count the days until you can leave.

There is a stable and mature cohort of midwives, who express frustration and dissatisfaction with their obstetric colleagues, a fact that was explicitly stated in the CQC report. One very senior midwife told me she sit’s in her car each day before work, feeling sick and scared, that something bad will happen, ‘Today will be the day I lose my licence to practice’.

Interventions thus far have only served to widen the gap, most of the team having recently received external human factors training- which according to a lead midwife, empowered the midwifery team to realise just how bad things really are.




 Clinical Vignette

03:00 The anaesthetic middle-grade on call is called to labour ward for an emergency caesarean section.

The patient has a working epidural, and has been taken into theatre by the time the anaesthetist arrives on the unit.

The obstetric team arrive, and despite several attempts by the anaesthetist to communicate with the obstetric middle grade about the urgency of the caesarean, there is no clear answer, the atmosphere in theatre is chaotic, the mother is distressed.

The anaesthetist makes the decision to give a general anaesthetic and treat as a category one section, although that would not be the technique of choice as the epidural could be rapidly topped up, and the mother could stay awake.

Despite introducing herself to the team, there were no team introductions. There was no time out. The patient was not draped whilst being prepared for the GA despite the request being made from the anaesthetist. The anaesthetist reported not knowing the locum surgeons name. No-one in theatre could be found who knew the surgeons name. There was no co-ordinated effort, and no leadership.

During the case there appeared to be significant blood loss. Due to not knowing the name of the surgeon, the height of the drapes, and a reluctance by to make eye contact, communication between the team was poor.

The anaesthetist searched for the surgeons’ name badge. Found the name, and using closed loop communication discussed the blood loss, and suggested pharmacological intervention. The rest of the case proceeded uneventfully.

The anaesthetist returned to theatre to debrief, but the rest of the team had gone.


 Surgical Safety Checklists

The World Health Organization (WHO) Surgical Safety Checklist (SSC) was devised to improve surgical outcomes. (4)  Step one, setting the scene of the SSC is for the team to introduce themselves and their role. Studies have shown that knowing the names of other team members greatly improves prevention of adverse outcomes (10) Despite the widespread use of the SSC and introductions at Hospital 1, recent personal experience suggests that operating theatre team members, may consider introductions to be another bureaucratic hurdle to starting a case instead of the safety check they were designed to be. Examples include: ‘Lord Darth Vader’ being the name announced by the surgeon during the team introductions (although this could be a humorous icebreaker), and newcomers being the only one to introduce themselves- as the rest of the team ‘already knew each other’. The end result is that the exercise may not attain the expected results, and team members may not actually know the names of the individuals with whom they are working despite having gone through the first step of the SSC.

A recent article published in the Joint Commission on Quality and Patient safety mirrored my experience. (11) Personnel were interviewed at the end of 25 cases where the SSC was used and asked to 1) name their colleagues in theatre. They were also asked 2) how important they believed it was to know the names of their team members, and 3) for their team members to know their name.

It found the surgeon knew the names of less than half of the operating theatre staff (44% p<0.001). Only 62% of staff knew the name of the anaesthetist. The circulating nurse (Theatre Assistant) was only known to 50% of people- in an interoperative crisis, this individuals' role is extremely important, misappropriation of time and tasks could take place if communication to this individual is substandard. The individual most likely to be correctly identified was the surgeon, this individual was also the person who felt it was important for others to know his/her name, and placed least importance in knowing the names of others. This could reflect a hierarchical structure which still dominates in theatres, of the surgeon as the captain of the ship- but belies an underappreciation of how using an individuals name permits a better atmosphere of trust, coordination, delegation, all facets of good leadership. In obstetric theatres, there are also other team members- midwives, midwifery care assistants, paediatricians, and of course the parents.  Improving communication in obstetric theatres by naming team members My plan involves improving knowledge of personnel names in obstetric theatres either by A) Having name/role on theatre cap, or B) Ensuring the whiteboard in theatre is updated for each case. It's obvious that people displaying names and roles will improve recollection of names and roles. It's also obvious that the WHO was sufficiently concerned about the impact of an inability for staff to know names and roles, that this was placed as item one on the surgical safety checklist. (4) We know from recent studies that despite the use of the SSC, names and roles are not remembered (11). The use of names on theatre caps represents a human factors solution- a system to better remember 'names and ranks', with the benefits of reduced cognitive burden during stressful situation, and improved team morale (12). Following the CQC inspection, the timing would seem pertinent to make such a change: One of the key recommendations from the CQC report being "Ensure all surgical procedures in theatre are supported by a world health organisation surgical safety checklist and five steps to safer surgery. This must be audited through observational audits and review of completed checklists."  Preparing for change Instituting a change is not always easy. (13) Image courtesy of google The uneasy alliance between status quo and innovative change has frequently been a source of challenge. The perception of when change is needed varies, thus creating the dilemma. (14) Making a change in medicine can cause clinicians to experience the unpleasant state of cognitive dissonance. Cognitive dissonance is viewed as a bias toward a certain belief or decision even though other information and factors may suggest otherwise. As a result, internal conflict arises, and cognitive dissonance can lead to irrational perceptions or rejection or denial of information. (15) We attempt to reduce the conflict by reducing the importance of facts, finding new facts to create a consistent belief system, seeking support from others with similar beliefs or attempting to persuade others to agree. Cognitive dissonance is more likely to affect those who feel defined by their decisions – therefore those who felt the SSC was imposed upon them, might find being asked to wear their name on their cap extremely uncomfortable, and unnecessary. The Kings Fund (13) recently produced a document called 'Embedding a culture of quality improvement' (2017). The first stated aim: Have a very clear rationale for why a quality improvement approach should be pursued. I set out to define the rationale:   Yes. Several recent critical incidents Improves teamworking morale and safety CQC, MDT Either names on theatre caps or on the whiteboard in theatre Can be done over next 6 months No WHO SSC Clinical leads for obstetrics, anaesthetics and midwifery involved CQC report Datix reports                     Image Adapted from www.IHI.org The next step is to assess and ensure that staff are ready for fundamental change (13) John Kotter. A professor at Harvard Business School and world-renowned change expert, introduced his eight-step change process in his 1995 book, "Leading Change." He describes an eight step process, and suggested that for change to be successful, 75 percent of an organisation's management needs to "buy into" the change. Therefore, I need to spend significant time and energy building urgency in step 1, before moving onto the next steps.                 Fully understand the implications a quality improvement approach has for the organisation's leadership There are various methods that NHS organisations can adopt to implement a quality improvement strategy – such as Lean, Six Sigma and Plan-Do-Study-Act (PDSA) cycles. Despite differences in terminology, they all draw on a similar set of tools and principles. The evidence suggests that no single quality improvement method works better than others; what matters more is having a consistent approach – in other words, choosing a model and applying it rigorously in practice.