Mandatory VTE assessment hit 95% compliance. National outcome data tell a different story.

Quality improvement · NHS · Venous thromboembolism

Mandatory VTE assessment hit 95% compliance. National outcome data tell a different story.

Scope of this post: This article is about the assessment-based process — how it was mandated, measured, and rewarded — and why national data suggest it did not deliver the guideline's stated aim. It is not an argument against thromboprophylaxis itself; that is a separate clinical question, covered in a follow-up post.

In June 2010, England launched one of the most ambitious patient-safety programmes in its recent history. Every adult admitted to an NHS hospital would receive a documented assessment of venous thromboembolism (VTE) risk. Thromboprophylaxis would follow for those who needed it. Trusts would report compliance quarterly. Financial penalties would bite if performance fell short. NICE had already published its guideline — CG92 in January 2010 — setting out what good prevention looked like. The aim was clear: reduce deep vein thrombosis (DVT), pulmonary embolism (PE), and the deaths that follow from hospital-associated thrombosis.

Fifteen years on, the compliance charts look like a quality-improvement textbook. National assessment rates climbed from roughly 53% in mid-2010 to above 90% within two years. From April 2013, when the target was raised to 95%, the NHS met it and kept meeting it — quarter after quarter, trust after trust. By 2019, the figure sat at 95–96% and barely moved. On paper, the programme worked.

But paper is the problem.

The wrong scoreboard

The NHS did not make thromboprophylaxis mandatory in the abstract. It made documented risk assessment mandatory — and then treated assessment completion as the primary measure of national success. CQUIN payments, standard-contract clauses, and board-level dashboards all converged on one question: was the form filled in?

That is a process metric — not whether the right patient received prophylaxis, whether doses were administered, or whether fewer patients developed clots. Root-cause analysis was part of the policy bundle, but compliance with assessment drove behaviour and reputation.

When a system optimises for what it measures, it should surprise no one when the measurement diverges from the outcome.

HES tells a different story

Hospital Episode Statistics (HES) do not record "hospital-acquired DVT" as a discrete field. What they do record — reliably, at national scale, year on year — is whether a DVT code appeared as a secondary diagnosis on an admission episode whose primary reason for hospital contact was something else. That is an imperfect proxy. It may include some pre-existing clots. It will miss silent events never coded. It cannot distinguish community DVT from thrombosis provoked by the index admission.

It is, nonetheless, the closest thing we have to a ten-year national signal of DVT arising in the context of hospital care — and that signal is not comforting.

Secondary DVT rate (England, HES)

Period	Per 100,000 episodes
2012/13	~166
2019/20	~210
2021/22	~225
2020/21 (COVID)	~253

Source: Hughes et al., BMJ Open 2025. SPC analysis shows significant upward trend from 2013 — when assessment compliance was already above 95%.

That is a red flag. It is proof that the assessment-based process the NHS built around the guideline — mandatory forms, compliance targets, central returns — did not produce the epidemiological pattern you would expect if that process were reliably reducing hospital-context DVT at scale. The failure lies in what was industrialised, not in the existence of thromboprophylaxis as a clinical intervention.

Compliance up. Secondary DVT coding up.
Those two lines were never supposed to run together.

The death data make it worse

If the assessment process were reliably triggering effective prevention among the patients the programme was designed to protect, we should see that in hospital-linked VTE mortality — deaths in hospital or within 90 days of discharge among people with a recent admission, with VTE on the death certificate. That is NHS Outcomes Framework indicator 5.1 (I00675), the official national outcome measure aligned with NICE's hospital-associated thrombosis framing.

Here the official narrative and the epidemiology part company.

The published story (rate) 72.8 → 62 Fatal VTE per 100,000 admissions 2007/08 to 2019/20 (61.2 in 2023/24) ✓ Widely cited as success

The epidemiology (count) 8,106 → 9,087 Absolute hospital-linked VTE deaths 2007/08 to 2019/20 (+12% pre-COVID) ↑ Significant upward SPC trend from 2013

The rate fell because the denominator grew faster than the numerator — adult hospital admissions increased by roughly a third over the same period — not because England was clearly putting fewer people in the ground from hospital-associated thrombosis.

A metric that dilutes the truth

Why does a falling rate mislead so convincingly? Because NHS OF 5.1 spreads fatal events across a denominator far broader than the population where those deaths actually occur.

National linkage work by Catterick et al. (BMJ Open, 2024), using the same case definition as the outcomes-framework indicator, found that 86% of hospital-linked fatal VTE followed emergency inpatient admission. Planned inpatient and day-case pathways together accounted for only about 12% of deaths — yet they form a large share of all admitted activity.

The indicator dilutes high-mortality emergency pathways across millions of lower-risk admissions.
A rate can fall while the count of people dying does not — and even rises.

Day cases are included in both numerator and denominator of OF 5.1, so a day-case surge could artefactually lower the rate. HES data rule that out: day cases rose in number but held at about one-third of activity for over a decade. Fatal VTE stayed anchored in emergency inpatient care. The problem is a rate-based metric on a heterogeneous admission base, sold on the promise of fewer clots and fewer deaths.

Well meaning guideline failed in practice

NICE CG92 — later updated as NG89 — describes a pathway: identify risk, prescribe appropriate thromboprophylaxis for those who need it, consider post-discharge extension where indicated, investigate incidents, learn from harm. That is more than a tick-box.

What England actually mandated and measured was the first step — documented VTE risk assessment — and treated completion of that step as if it stood for the whole pathway. Form completion, central reporting, and a 95% compliance target became the national product. Thromboprophylaxis remained in the guideline text; it did not become the national scoreboard.

That substitution is why I regard the guideline as well meaning but failed in practice: not because prevention is futile, but because the assessment-based process given statutory force was the wrong proxy for it.

Process–outcome decoupling

Metric	What happened	Signal
VTE assessment compliance	Target met, sustained, celebrated	✓
HES secondary DVT	Upward trend through compliance era	↑
Fatal VTE (absolute deaths)	Flat to rising from 2013; SPC significant	↑
Fatal VTE (published rate)	Modest decline; cited as success	↘

We optimised documentation and called it prevention.

What should change

Assessment completion should be a gateway metric, not the finish line. Outcomes would be tracked in absolute terms and pathway-specific strata — emergency medical admissions first — with prophylaxis administration audited alongside forms. Secondary DVT in HES would be monitored as a sentinel, coding caveats acknowledged but not deployed to dismiss the signal.

The lesson generalises beyond thrombosis. When a guideline becomes mandatory NHS activity with financial teeth, ask which part of the pathway was actually enforced. If the answer is a single process step — here, risk assessment — you may get excellent compliance on that step and no superior clinical outcome on the harm the guideline was written to prevent.

Coming next: Thromboprophylaxis on its own terms — evidence, delivery, and outcomes. This post stops where the national programme stopped measuring: at the form.

The clinical intention was humane. The assessment-based architecture was not equal to it.

References

1. NICE. Venous thromboembolism in over 16s (NG89). nice.org.uk/guidance/ng89
2. NICE. VTE: reducing the risk for patients in hospital (CG92). nice.org.uk/guidance/cg92
3. Department of Health. Report of the Independent Expert Working Group on Prevention of VTE. 2007.
4. NHS England / NHS Digital. VTE risk assessment quarterly data and CQUIN specifications, 2010–2020.
5. Catterick MD, Hunt BJ. Impact of the national VTE risk assessment tool in secondary care in England. Blood Coagul Fibrinolysis. 2014;25(6):631–635.
6. Hughes F, et al. HES DVT/PE trends. BMJ Open. 2025. doi:10.1136/bmjopen-2024-090301
7. Catterick MD, et al. Who dies from VTE after hospitalisation in England? BMJ Open. 2024. doi:10.1136/bmjopen-2023-078898
8. NHS England Digital. NHS Outcomes Framework 5.1 (I00675). Feb 2025 release
9. Nuffield Trust. Blood clots following hospital care. nuffieldtrust.org.uk
10. NHS England Digital. Hospital Admitted Patient Care Activity (HES). digital.nhs.uk
11. Hunt BJ, et al. VTE prevention: UK experience. Res Pract Thromb Haemost. 2023. PMC9903667

Surgical Swab - tail it, tag it, secure - then let us see how many are lost

Retained Swab after surgical procedures

Surgical Swabs – tail it, tag it, secure it – and then let us see how many are retained.

Swabs retained in patients’ bodies after surgical procedures are thought to happen from 1 in 500 to 1 in 5000 patients. However, NHSLA data would suggest that it happens much less often (possibly rarer than 1 in 10000 during caesareans). The point is not about the numbers or frequency or other statistics. Firstly, a retained swab is a completely avoidable complication. More importantly, the impact on patients’ lives can be extremely profound when a swab is left behind with infections, difficulty in diagnosis of the complication, re-operation, all sorts of other complications and death.

The impact on the doctor is also serious though not as much as for the patient. It seems that an average surgeon could have a 1 in 3 or 1 in 4 chance of a retained swab happening by his/her hands.

The primary responsibility for all instruments, needles, swabs and in general, anything that happens during a surgical procedure belongs to the operating surgeon. The primary method now used to ensure that a swab is not left in a patient is operator memory, as we all know memory is a fallible method to ensure patient safety. The adjunct to memory is the intra-operative swab notes/notices where the surgeon tells the scrub nurse a swab is placed within a patient, the scrub nurse tells the runner nurse who writes on the theatre white board and at the surgeon tells the scrub nurse when the swab is removed, the scrub nurse tells the runner nurse who removes the note from the board. This six or eight step communication is prone for failure once again because the initiation point is the surgeon’s memory (remembering to mention) and then simply by the number of steps involved in the communication.  

The current next step currently taken is the end of procedure swab count – this happens at the end of the procedure when swabs are counted and confirmed as matching the number of swabs that were opened for use during the procedure. This is actually not a prevention method, this is technically a detection method to confirm that a swab has not been missed, at the best a secondary method of ‘prevention’. 

When a swab count shows a missing swab x-ray is used to detect if a swab is retained within a patient. Surgical swabs these days have a radio-opaque line so that a retained swab can be detected by an on-table x-ray when the swab count detects a missing swab; this is a tertiary or third order issue for detection of a missed or retained swab and does not prevent the swab going missing in the first place. The x-ray method has a known but rare rate of failure in detecting a retained swab.

We know that the current methods are failure prone. The primary prevention methods are memory based – hence fallible under stressful complex conditions.

The swab count, is post-hoc (post procedure), after the event, hence a swab count does not act as prevention, it only acts as a detection method in an area where primary prevention method is highly fallible.

It is known that mechanical methods are better than memory alone. It is best to agree on a single mechanical primary prevention method so as to either enhance the effectiveness of the secondary prevention or to make it a luxurious yet essential redundant detection mechanism.

TYPES OF SURGICAL SWABS

In the context of retained swabs, surgical swabs during intra-operative use are of two kinds:

Held swab: one that does not leave the surgeons’ (or the assistant’s hand). The swab can be held in two ways a) directly held (surgeons’ hands) b) indirectly held (swab on a stick)

Free swab: is one that is placed within the patient by the surgeon and does not have contact with the surgeons’ hands for any period of time.

A directly held swab has no risk of being left in the patient – by definition a directly held swab does not end up being a retained swab.

An indirectly held swab has a small risk of ending up retained in the patient if the swab slips unnoticed (this is especially possible in the case of pledgets).

A free swab has the highest risk of being retained in the patient. Hence a primary mechanical prevention method is essential for a free swab, irrespective of the swab’s size or the anatomical site of use. Let us look at a method that could prevent a swab from being retained in the first place.


METHOD OF PRIMARY MECHANICAL PREVENTION TO AVOID A RETAINED SWAB

Tail-Tag-Secure is a must for Free Swabs

TAIL: Free swab must always have a tail (taped swabs) which extends outside the wound/incision. This tail could be part of the swab which is extending out of the wound or a formal tail from the swab.

TAG: At the end of the tail which is outside the wound the tail must always have a tag (clip/artery forceps or other instrument holding on it) so that it does not migrate inadvertently into the wound. 

SECURE (the tag): The purist is welcome to secure this tag (clip/artery forceps or other instrument) to the drape as a third level safety procedure, using another instrument. 

TAIL-TAG-SECURE means there is a constant visual reminder about the swab inside the abdomen and a mechanical hindrance to closing the wound acting as a second level safety mechanism. 

The recommendation is that all Free Swabs (any swab that is within a patient and does not have contact with the surgeons’ hand at any point of time), irrespective of the size of the swab or the anatomical site of its use must have a tail (tape), must be tagged (with a clip, artery forceps or other instrument) and most often be secured (to the drape using another instrument or an adhesive sticker). 

This makes the swab count a needed redundancy in the system which is what a detection method should be rather than the surgeons’ memory or a multi-point communication system both of which are potentially highly unreliable as a prevention methods.

A number of surgeons are already using this method. Obviously when these methods are insisted upon, there will be resistance and arguments that may sound valid; however, we know the current method does not work, we know that a retained swab is completely avoidable, we know that a retained swab is designated as a never event. It is time to look for and implement a different and a better solution – the tail-tag-secure is hence essential.

Electronic chip embedded swabs and routine scanning of patients before closure of the wound would be a technology intensive (and possibly costlier) solution. We may be far away, if at all, from completely absorbable swabs. We don’t know if these would have their own problems.

Current Method of primary prevention	Suggested Method of primary prevention
Memory based (fallible): Surgeon’s memory	Visual and Mechanical methods (more reliable)   Tail (tape) – Tag – Secure the swab
Multi-person Communication based (fallible): Notes on the theatre board
Detection methods (swab counts, x-ray) remain essential

 

 

©M HEMADRI

Follow me on Twitter @HemadriTweets

Blondes, pilots and doctors. Who should learn from whom?

Blondes, pilots and doctors – who should learn from whom?

The Malaysian Airlines plane disappearance remains a very sad mystery. Our hearts go out to the missing persons and their families/friends, it must be unbearable agony.

Now we hear in the papers that young blonde girls were entertained in the cockpit in 2011 by one of the pilots of missing plane. http://www.dailymail.co.uk/news/article-2578146/Young-blonde-says-missing-Malaysia-Airlines-pilot-invited-friend-ride-cockpit-entire-flight-2011.html

I am not taking any moral stand here, pilots or anyone are welcome to entertain blonde girls or any other type of women or men anywhere. My problem arises when these pilots put passenger safety at risk by such acts.

I heard this news on the morning of 12 March 2014 on my way to the CHFG conference in Birmingham. I would have normally laughed out loud, then stay angered for a while and then move on. But there was something else bothering in my mind. Then at the conference, as in any healthcare conference these days, I heard a number of people repeating what has now become a cliché that healthcare should learn from pilots and airlines. What was bothering me then surfaced to provoke me into writing this blog.

If you thought for a minute that this cockpit privilege is dished out only in Malaysia or in some other distant country, you are probably mistaken and it may be time to change your mind.

A few weeks ago a colleague who is a senior doctor with additional responsibilities in the UK told me about travelling in the cockpit of a major airline on a scheduled short haul international flight in Europe. It was obviously very thrilling for the colleague but as a safety enthusiast it was disturbing me. As a senior doctor it might have been appropriate to decline the offer on the grounds of ensuring safety; that is another debate. If that colleague lied to show off etc that is a personal probity issue.

Then the colleague said that this privilege was also offered to another family member a couple of months earlier, who took a flight in the same sector for stag or a hen night. This is even more unsettling since it seems such behaviour by pilots are not one off or localised but probably frequent and international. Update: Since this blog was originally published about 48 hours ago, I have had a very senior doctor now retired telling me that he sat in the cockpit while flying over the Alps on the way to Italy. Goes to show that it is not only localised and frequent, it is also chronic poor behaviour by pilots.

I think the constant bu*****t about healthcare learning from pilots has to stop. This blog has argued for healthcare to learn from all sorts of good sources. I have previously written about animal air transport. I have written on the pilot error rates not falling since 1950s and the very large variation seen in the 'ultra-safe' airline industry. I still believe that healthcare needs to learn from everyone including airlines. But it should not be one-way traffic. Perhaps pilots can learn from doctors who will not pick out anyone from a waiting room on the basis of hair colour or allow 'friends' to join them in operating theatres as a thrill of the day.

We should not also make the error of mistakenly attributing the improvements allowed by technology as advances in human behaviours and interactions.

©M HEMADRI 

Follow me on twitter @HemadriTweets

Scheduled airlines are safe – just like out patient clinics

http://successinhealthcare.blogspot.co.uk/2012/09/scheduled-airlines-are-safe-just-like.html

Healthcare is not similar to aviation but lessons can be learned http://successinhealthcare.blogspot.co.uk/2012/04/healthcare-not-similar-to-aviation-but.html

In search of immortality

The media screams out relentlessly on excess deaths, avoidable deaths, harm, on how many lives can be saved if healthcare did this, that or the other right. In fairly cynical mood I thought, if I added up all the number of lives the media says we could save the people in UK could become immortal. Thus started my quest for immortality.

Here is the list and total of how many lives the media thinks healthcare can save.

1	Preventable DVT deaths	25000
2	Kidney function tests	42000
3	Addiction deaths	150000
4	Child deaths	2000
5	Learning disability	1200
6	Cancer deaths	11500
7	Maternal deaths	50
8	Not taking tamoxifen	500
9	Dehydration in the elderly	130
10	Wrong medication deaths	11
11	Sepsis	15000
12	Flu jab	7000
13	Trauma admissions in hospital	600
	Total	254991

I am sure you the reader can add a few of your own categories to this list.

The total number of people dying every year in UK 428367. If we can save 254991 that means we will be 60% of our way to making UK immortal.Obviously there are undefined overlaps between the categories and I sure double or triple or multiple counting makes all that number attract attention.

Let us get a little real now. No one thinks they are going to to be immortal. Everyone knows there is avoidable/preventable mortality in healthcare delivery. The point is to try to admit, then identify avoidable deaths, followed by measures to reduce avoidable deaths to zero or awfully close to zero.

Would that be possible? 

The above media based list includes untimely or early deaths due to life style and behavioral choices. While solving that would also be possible, I am not talking about that. I am talking about deaths that can be avoided by delivering the healthcare in a way that we intended it to be delivered. 

United Kingdom has an amenable mortality of 102 per 100000 population (which works out to an approximate 65000 people) compared to France's 64 per 100000. It seems like a 40% reduction in amenable mortality should be possible. Since France's 64/100000 mortality is also amenable to healthcare it means we will have a lot of smart work to do for quite some time to come.

Can it be done?

We have already set the background by talking about HSMRs as an indicator, we have discussed the broad ideas around methodology in Hemadri's Four Fundamentals (http://successinhealthcare.blogspot.co.uk/2012/01/hemadris-four-fundamental-questions-for.html), the issue of learning facts yet practising opinion and how to over come it in Letter to my nieces (http://successinhealthcare.blogspot.co.uk/2012/09/letter-to-my-nieces.html).

The current argument in UK is on how to actually identify the avoidable deaths. Individual case note reviews is thought to be the method. It may well be. There is a specific way of performing these individual case note reviews. 

Watch this space. The blog with some ideas on performing case note reviews will be here soon.

The quest for immortality - no that does not continue. The quest for eliminating avoidable deaths continues.................................

  
©M HEMADRI

 

Follow me on Twitter @HemadriTweets

Weblinks for each of the 13 headings which are listed above:

 

http://www.nhs.uk/Conditions/Deep-vein-thrombosis/Pages/Introduction.aspx

http://www.bbc.co.uk/news/health-23850838

http://www.dailymail.co.uk/health/article-139995/Addiction-biggest-preventable-killer-UK.html

http://www.theguardian.com/society/2013/jul/13/preventable-child-deaths-nhs

http://www.mencap.org.uk/news/article/1200-avoidable-deaths

http://www.cancerresearchuk.org/cancer-info/news/archive/pressrelease/2012-03-06-ignorance-adds-thousands-to-cancer-death-toll

http://www.cdph.ca.gov/data/statistics/Documents/MO-CAPAMR-CMACE-2006-08-BJOG-2011.pdf

http://www.bbc.co.uk/news/health-23959070

http://www.independent.co.uk/news/uk/home-news/hundreds-have-died-of-dehydration-in-care-homes-2199192.html

http://www.telegraph.co.uk/health/healthnews/10020997/Eleven-NHS-deaths-from-wrong-medication.html

http://sepsistrust.org/

http://www.telegraph.co.uk/health/8595005/Flu-jab-for-all-under-fives-could-save-thousands-of-people.html

http://www.official-documents.gov.uk/document/hc0910/hc02/0213/0213.pdf

 

Don Berwick Report

Don Berwick NHS patient safety report - will it work?

It will. Though there is a blind spot to watch out. 

A blog from a particular perspective

Don Berwick report 'A promise to learn, a commitment to act, improving the safety of patients in England' has been published (https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf). There is all round praise which is well deserved. The entire report is full of gems of wisdom. As a practising clinicians who also values work life balance, I have still managed to fast read the report, I will read it again in detail. As a student of improvement science I am sure I will learn a lot from the report. I am a fan of Don Berwick, I have heard him speak a number of times and every time I am not only moved but I always come away with great learning. It was one of the cherished moments in my professional life when I shook his hand at the Forum in London in April 2013 and he walked with me to personally introduced me to Sir Brian Jarman.

Don's report is pretty comprehensive as expected, I hope the report will be effective.

The Blind Spot

My problem with the report is not the content, my problem is with the membership of the advisory group. It is elementary in leadership that while what is said does matter, how it is said and who said it really matters more. Why do you think football celebrities endorse non-sports products?

The committee was happy that they were independent.

The advisory group was made up of 17 persons whose expertise is unquestionable. 4 of them were Americans from the Boston-Harvard area; with 3 of the 4 Americans from the same organisation. 12 out of 17 were non-NHS, the 13th was NHS Scotland. No Europeans. No one else from the US aside or instead of this close knit group.

9 of the 17 were women - finally it looks like we are recognising that the half the real world is indeed made up of a gender who are not male, well done. 

17 out of 17 seem to be white. 

Don Berwick is no stranger to England, he is no stranger to inclusive leadership. Don was obviously so dedicated to answering the questions put to him that his human limitations prevented him from recognising that in London when he walks the streets 50% are foreigners, 40% are Black and Minority Ethnic. If Don entered any hospital he may have noticed that about 40% of doctors are from BME origins and in London nearly 40% of healthcare staff are of BME origin and about 10% of this country are from BME backgrounds. Don's report speaks about adequate staffing. Where do you think that comes from? We are hearing reports of urgent recruitment of rota fodder to deal with the A&E staffing crises from countries like India, Don and his committee would recognise Indians are part of the BME group.

The Quality Chasm and Leadership Deficit

Who speaks to whom matters. Constituencies matter. Don is now a politician, he will do well to remember that his country's president won his office on the black vote (though certainly not exclusively on the black vote). If Don looked and did not find an person who has some expertise in quality and safety who also happened to be non-white he should have mentioned that a part of the system failure that he talks about.

The report talks about culture and fear. Amongst the most afraid in day to day clinical practice are BME doctors who face a higher rate of referral to their regulator; they are also thought to have higher rate and higher intensity of sanctions by their regulator. BME doctors also face extraordinarily adverse pass rate in their specialist examinations, unlike in Don's country.

It is not as though the committee did not have a BME connection. It did have a most profound and tragic BME connection. Lisa Richard Everton, a patients' representative on the committee lost her husband Paul Everton due to a lethal overdose at Heartlands. Paul Everton was black. Don would know that in our much revered NHS BME's get poorer health outcomes.

I was actually hoping to have interactions, debates or arguments on the technical aspects of improvement and patient safety issues with Don; I am sure I will in the near future. Instead I am talking about leadership, culture, inclusivity and race. On my initial reading, the report excels and succeeds at the theoretical and technical aspects where the content experts lead by example. The report fails in its operational aspects especially in the context of what the manpower constituency might recognise, mirror and reflect, the report and its committee fails by example

The inability to include or cope with a real mix of normal people is the biggest wall that prevents our already good NHS from achieving even higher standards. A different committee with some persons who have BME style thinking (as opposed to just simply being from a BME origin) in it would not have made any difference in the content of the report, I suspect it might have made a difference in the sincerity and speed of adoption. I am not a race warrior, this blog is not about race, regular readers of this blog would already know that. This blog is about contextual leadership which in essential for success in healthcare.

I remain a fan of Don Berwick, I do not write this in protest or complaint. I write this due to a genuine concern that Don, a person whom I admire and his recommendations should not fail. I write out of a genuine desire that the NHS should cross the quality chasm by overcoming the massive leadership deficit that it faces.

© HEMADRI

Follow me on twitter @HemadriTweets

PS: I recommend the report. It is up to us, normal NHS staff to make sure that we take this report to the front line and deliver it there to benefit our patients.

Mark the site campaign

MARK THE SITE
 

A Surgeon's interaction in the Operating Theatre

This is a real conversation that happened in a real surgical operating theatre in India a few weeks ago. It probably happens every day.

Surgeon, standing to the right of a patient under general anaesthesia for hernia repair asks: 'which side is the hernia?'

Assisting surgeon: 'I don't know. I did not see the patient.'

Surgeon: 'Who saw the patient?'

Assisting Surgeon: 'The house surgeon from the previous shift'

Surgeon: 'What does it say in the notes and consent?'

Assisting Surgeon: 'Hernia repair, obviously'

Surgeon in anger: 'Obviously!! But which bloody side?'

There were a large group of people in that operating theatre, junior nurses, medical students and other staff. None of them will speak to the chief unless they are spoken to. Silence for a few moments.

Surgeon in exasperation: 'Does anybody know the side?'

Medical Student puts her hand up.

Surgeon very impatiently: 'Tell us. What are you waiting for?'

Medical student says: 'I don't know for sure, but I was standing on the right of the patient's bed when I examined him and I had to reach out across to feel the hernia. So it must be the left side.'

Surgeon: 'Left it is then. Let us get this done'

Very lucky day. The patient did have a left hernia. The medical students had seen two other hernia pre-op patients the same day and extremely fortunately they were all left groin hernia.

Wrong Site Surgery WSS

(and wrong site procedures: wrong site anaesthetic, implement fitting, etc)

Sadly not all patients have lucky days like the above patient.

Wrong site surgery happens 40 times a week in the USA. http://www.washingtonpost.com/national/the-pain-of-wrong-site-surgery/2011/06/07/AGK3uLdH_story.html

Wrong site surgery is estimated to happen once a year in a typical hospital with 300 beds Clarke, J.R., Johnston, J., and Finley, E.D.  Getting surgery right.  Annals of Surgery;246(3):395-405, Sept. 2007.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1959354/pdf/20070900s00006p395.pdf

Surgeons have a 1 in 4 chance (i.e a very high chance) of being involved in a wrong site incident

Wrong Site Procedures: Wrong side anaesthetic – is happening more and more with not much attention paid to it. There are a number of interventions done in wrong patients, a large number of unnecessary procedures done on right patients. Even the statistics for these are difficult to find.

Though the evidence comes from the west there is no reason to believe that other countries (such as India) have any less incidents or better practices.

The impact of these are dreadful with life long suffering. Life long dialysis if the wrong kidney is taken out or a kidney transplant with the complex lifelong medication to be taken after that, wrong eye – blindness, wrong leg, etc. It does not need to be major operations even after lesser wrong procedures it is possible to have wound infections, chronic wound pain etc. These are just physical. The psychological effects are much worse and affects not just the patient but families, friends and whole communities. Trust in healthcare providers – hospitals, doctors, nurses – irreversibly damaged.

The internet is full of events, episodes and tragic histories of patients who have suffered wrong site surgery. If you want examples they are only a couple of clicks away.

Solutions

It is very easy to write about solutions but it is well recognised that any solutions against wrong site surgery is very difficult to put into place, difficult to practice and not always successful. That is no reason not to try to reduce it by any means possible.

Some of the more effective solutions are thought to be:

The operating surgeon to see the patient on the day of the surgery and MARK THE SITE on the incision or as close to the incision as possible.

If the procedure involved a symmetrical organ the opposite side i.e. the side without the pathology is marked with a big NO; that may help.

Some surgeons write the name of the procedure (including the side if appropriate) on the incision line – that helps.

Check lists that include surgical site marking

Improving the culture so that any member of staff however low down in hierarchy is able to speak up when WSS issue is suspected

Our own suggestion (though not research based) is to empower the patient by asking a competent patient (any one who is able to give consent should be a competent patient) or a competent relative to mark the site of the procedure in the presence of the operating surgeon. After all it is reasonable to assume that the patients have a vested interest in the surgeon not operating on the wrong part of their body.

Even if it is a non-symmetrical organ procedure or a midline procedure make it a habit to mark the patient so that you can have standardised preparation protocol. It will really help a patient some day, if you are a doctor it will surely help save your career.

MARK THE SITE

This is a campaign we are specifically starting for South Asian countries (e.g. India) but is also relevant to many developing healthcare systems (e.g. African continent).

Surgeons

Please pledge today that you will mark the site of the incision on all patients on the day of the surgery.

Anaesthetists

Please pledge today that you will not begin anaesthetising a patient unless you see the site marked on the patient's body. If there is no mark please ask your surgeon to check and mark it before anaesthesia is commenced.

Nurses

Ward Nurses: Please pledge today that you will not let any surgical patient leave your ward to go to operating theatres unless their surgical incision site is marked by the operating surgeon.

Theatre Nurses and allied theatre staff: Please pledge today that you will not allow patients through the main doors of the theatre unless you see the surgical incision site marked.

PATIENTS (and relatives)

Please pledge today that you will not leave the ward/bed and enter operating theatres unless there is a mark on your body at the surgical incision site.

Pharma companies and their sales reps
Please provide doctors with a skin marker pen as a part of the various complimentary items that you provide and ask the doctors to use them to mark the surgical incision site

Everyone

Please forward the link for this blog to at least two persons. Alternatively cut and paste and send the information to at least two persons.

Write to hospitals, politicians, news media outlets or any other action that spreads the message.

Let this be a campaign be owned by us the normal public (such campaigns are normally lead by institutions/organisations/etc)

Primum non nocere is a fundamental principle of medical practise. Causing permanent harm by wrong site surgery is against that principle. It may not have happened to you yet but look at the numbers it is happening all over the world, it may happen to you unless you take definite action about it; irrespective of whether you are a healthcare professional or general public.

MARK THE SITE

©M HEMADRI 

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