Identifying resilience: a system safety review of trauma and orthopaedic theatres

Abstract

A prospective, qualitative study, of trauma and orthopaedic theatres was undertaken using the CARe QI handbook and the SEIPS framework, with the aim of preventing future Never Events. The study demonstrated a new approach, focussed on understanding ‘work as done’ to identify opportunities to improve system resilience, tested, using the Model for Improvement. Undertaken during the Covid-19 pandemic, it demonstrates that such conditions should not be a deterrent to observational studies, but requiring greater time and resource than a standard investigation, the approach may not align with current organisational or regulatory expectations. At the conclusion of this study, the mean time between Never Events in theatres had increased from 46 to 224 days, an achievement that had not previously been possible using the regulatory required, safety I, investigatory approach. These findings should be used to inform future PSIRF and Never Event Frameworks, to ensure effective systems-based analysis and improvement.

Practitioner Summary

The value of applying a prospective approach, incorporating system resilience and quality improvement in response to adverse safety events, was demonstrated, whilst highlighting the time and resource necessary for success. This study supports the recommendation that the use of the prospective systems-based approaches introduced by PSIRF, should be applied to never events.

Keywords:

• Resilience
• never events
• quality improvement
• systems
• healthcare

Acknowledgements

This work was supported by the staff within Gloucestershire Hospitals NHS Foundation Trust. The opportunity and practical application were possible due to the support of Andrew Seaton, Quality Improvement and Safety Director and Kayzia Bertman, Quality Improvement & Project Lead for Theatres.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.