Why the study?
It was unclear how the WHO Surgical Safety Checklist is being applied and why intraoperative Never Events continue to occur over a decade after its introduction.
A lack of training and engagement with human factors may explain the continued occurrence of intraoperative 'Never Events' despite the use of the Surgical Safety Checklist.
May prompt enhanced human factors training; leaves open whether interventions reduce never events.
This paper examines the application of the Surgical Safety Checklist (SSC) within NHS hospital operating theatres England. The aim of the study, through a combination of open-ended questions, was to solicit specific information including views and opinions from operating theatre experts to establish from how the World Health Organisations (WHO) SSC is being applied, and therefore and why intraoperative ‘Never Events’ continue to occur more than a decade after the SSC was introduced. Participants were from the seven regions identified by NHS England. The intention of this paper is not to establish definitively whether the quantitatively identified themes; including a lack of training and engagement with human factors explains the increased presence of intraoperative ‘Never Events’. However, these themes, when subjected to methodological triangulation with the current literature, do appear consistent, and therefore provide an exploratory approach to inform research intended to improve safety in the operating theatre by informing policy and its application to safe practice ultimately towards quality improvements.
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Roberts et al. (2023) studied this question.
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