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STANDARD OPERATING PROCEDURE TO ENSURE “FIVE STEPS TO SAFER SURGERY” INCLUDING “WHO” CHECKLIST ARE COMPLETED CORRECTLY.
Process Name: (^) Process to ensure compliance with 5 Steps to Safer Surgery
SOP Number: (^) WHO checklist Version Number: 1 Effective Date: (^) 01/02/2018 Review Date: 31/05/ Author: (^) Wendy Hartley
Process Owner: (^) Anaesthetics and Surgery Directorate Name/Position: (^) Directorate Manager Date Approved: May 2018
Background
The Safer Surgery Saves Lives initiative was launched by the World Health Organisation (WHO) in 2008 to reduce the number of surgical errors and enhance patient safety during the perioperative phase of their care. The launch saw the introduction of a surgical safety checklist. The Five Steps to Safer Surgery was introduced in 2010. It is a process for improving the way theatre teams communicate with each other. It consists of 5 steps:
**1. Briefing
- Sign in
- Time out
- Sign out
- Debriefing**
The WHO surgical safety checklist forms steps 2, 3 and 4 of the five steps.
Assessment
The WHO surgical safety checklist is a core set of safety checks, identified for improving performance at safety critical time points within the patients perioperative journey. The 3 steps in the checklist are not intended as a tick-box exercise but as a tool to initiate effective communication between the clinical team. The WHO checklist should be carried out for all patients including those having procedures under Local anaesthetic or sedation. The Briefing and Debriefing should be carried out for all theatre lists and should include all members of the theatre team.
Objectives
- To ensure a safe operating environment for patients and staff
- To reduce the number of Serious incidents and Never events
- To complete WHO checklist for all patients
- To improve efficiency and safety through effective Briefing
BTHFT Standard Operating Procedure to ensure Five Steps to Safer Surgery including WHO Checklist are completed correctly
- To improve practice through effective Debriefing
Scope
Briefing to be carried out prior to the start of all theatre lists and to include the whole team. Debriefing to be carried out at the end of each theatre list and to include the whole team. The WHO Surgical Safety checklist to be completed for all patients. The Five Steps to Safer Surgery to form part of all theatre staff, surgical and anaesthetic trainees induction to the Trust.
Stages of the Process
Briefing
Purpose Team briefing is an opportunity for highly effective face-to-face communication which can enhance team performance however; it must be focused and supportive. Briefing facilitates delivery of clear messages and reduces misunderstandings; it is not just about informing people, but listening and responding to questions and concerns. It is essential that all staff feel able to speak up and that senior members of the team actively welcome queries from more junior ones. Briefing can help to clarify the aims of the team and sets the tone for a professional working environment.
Teams are encouraged to refer to the briefing prompt sheet (Appendix 1) to aid the conduct of the briefing.
General Points
- The briefing should be attended by the whole team and carried out before the list starts.
- Due regard to patient confidentiality must be given. Briefing should take place in a quiet room with the door closed – the anaesthetic room is ideal.
- The briefing can be led by any member of the team who must encourage open communication.
- All team members must be able to see a copy of the list during the briefing.
- Use the Pre-Operative briefing prompt sheet and Issues log or Theatre team Briefing and Debriefing record Introductions
- All members of the team must introduce themselves: this emphasises that every team member has a duty to speak up and to be heard.
- All team members must state their role and are encouraged to declare if they are new to theatre or unfamiliar with the department. This is an opportunity to make them feel welcome.
BTHFT Standard Operating Procedure to ensure Five Steps to Safer Surgery including WHO Checklist are completed correctly
Time Out
All activity must STOP to allow staff to focus on the TIME OUT. The purpose of the TIME OUT is to ensure that the correct procedure is undertaken on the correct patient and that the correct measures are in place to prevent patient harm.
- This must be completed by the whole team
- TIME OUT should be completed after the patient has been safely positioned and appropriate monitoring is attached
- TIME OUT will usually be completed once the patient is prepped and draped however, in some specialties, it may be appropriate to do the TIME OUT before draping. It is essential that TIME OUT is done prior to incision.
- All questions must be read aloud and the box ticked on confirmation (questions must not be asked from memory)
- Patient identity must be confirmed by reference to patient ID bands
- Operative site must be confirmed by reference to the patient procedure band, surgical site marking, consent form and operating list.
- Displayed imaging must also be identified as being the correct patient
- Surgery should not commence until any discrepancies have been resolved
- No other activity should be happening whilst the TIME OUT is being completed
Sign Out
All activity must STOP to allow staff to focus on the SIGN OUT. The purpose of the SIGN OUT is to ensure surgery has been completed in its entirety, documented accordingly and to
ensure ongoing safety of the patient beyond the theatre.
- This must be completed by the whole team
- SIGN OUT must be completed before any member of the team leaves the Operating theatre (following the first count, before the surgeon leaves the table and before the anaesthetist starts to wake the patient)
- All questions must be read aloud and the box ticked on confirmation
- The patient must not leave the theatre until any discrepancies have been resolved
- No other activity should be happening whilst SIGN OUT is being completed
BTHFT Standard Operating Procedure to ensure Five Steps to Safer Surgery including WHO Checklist are completed correctly
Debriefing
Purpose Team debriefing is an opportunity for the team to review their performance during the session and to identify positive achievements and areas that need to be improved. It is an opportunity to acknowledge good performance, say thank you and to boost team morale. As with briefing, it essential that the debriefing is conducted in a professional manner with all staff members encouraged to contribute and all listened to respectfully. Teams are encouraged to refer to the debriefing prompt sheet (Appendix 1) to aid the conduct of the debrief.
General Points
- Debrief should be attended by the whole team and carried out at the end of the list prior to any member of the team leaving the theatre suite.
- The debrief can be led by any member of the team who must encourage open communication.
- Consider Scheduling, Equipment, Safety and Team work/communication
- Review what went well
- Record actions needed in an Issues log or Theatre Team briefing and Debriefing record
- Each action needed must have a clearly identified person responsible for dealing with it
- Threats to safety must be escalated to senior staff and an incident report completed.
Review
This SOP should be reviewed annually unless new guidance or policy dictates a review any sooner.
Monitoring Compliance with the SOP
Requirement to be monitored. Must include all requirements within NHS LA Standards
Process to be used for monitoring e.g. audit
Responsible individual/ committee for carrying out monitoring
Frequency of monitoring
Responsible individual/ committee for reviewing the results
Responsible individual/ committee for developing an action plan
Responsible individual/ committee for monitoring the action plan N/A Datix incidentreports^ Theatre TL’s /Matron / DM^ Daily^ Theatre TL’s/Matron meetings
Theatre TL’s/ Matron /DM
Directorate Governance Meeting BTHFT Standard Operating Procedure to ensure Five Steps to Safer Surgery including WHO Checklist are completed correctly
