The aim of this study is to determine whether the implementation of introducing names and role delegation onto theatre caps can reduce errors and improve patient safety, especially in children’s nursing. For the purpose of achieving this particular aim, the study will also have some key objectives. These include, to search and identify the available literature materials that are most relevant to the research question and to determine the importance of introducing names onto the theatre caps. It was also be the objective of this study to examine the importance of introducing role delegation. The research involved the use of a descriptive survey research design and a questionnaire as the data collection tool. The PDSA was the service improvement strategy employed for the purpose of this study. The study also involved the use of three online search databases that include Medline, CINAHL as well as Cochrane. The study found that the implementation of introducing names and role delegation onto theatre caps is important practice and that it will reduce errors and improve patient safety in the future.
Introduction to Service Improvement
Service improvement (SI) in health care is a methodical approach that uses precise techniques to measure and deliver continual improvements in the quality of a service (The Health Foundation, 2010). Whilst SI in the National Health Service (NHS) can improve provision, reduce costs, streamline services and reduce errors in practice, Craig (2018) argued that it may not be adequate for improving outcomes and quality of care when used alone. The Kings Fund (2012) agree nurses should be engaged and actively involved in developing a shared vision of the quality improvement strategy, however, they suggest the biggest weakness is its failure to engage clinicians in management and leadership roles. Additionally, they state that engaging staff is essential in making change and improvement happen to deliver a better patient experience with fewer errors for SI to be sustained.
The NHS Institute of Innovation and Improvement (NHSIII) (2009) highlighted the relevance of SI stating that each social care provider is encouraged to work within a team whilst still improving their own part of the service. All health care personnel must adopt change and support staff to enhance their services (NHS Institute for Innovation and Improvement, 2009). Whitby (2018) further describes improvements in care to be a widespread development of leadership skills in front-line nurses with the strongest and most immediate influence on staff behaviour, emphasising nurses and ward managers are well placed to improve organisational cultures and implement necessary changes in their practice setting.
An inspection from the Care Quality Commission (CQC), an independent regulator of health and social care in England found that services were failing across several departments at The Royal Cornwall Hospitals NHS Trust (2017), these failures caused patients to suffer partial loss of vision or complete blindness, they also reported that patients died as a result of poor care. The report identified persistent evidence of care that fell below standard and the trust was placed in special measures. Without intervention from the CQC the findings would have been more catastrophic. The Nursing and Midwifery Council (NMC) (2017) and the CQC now work in partnership to promote patient safety and improve service, a driving force for the NHS, similarly NHS England and NHS Improvement recently came together as a single organisation, likewise to better support the NHS and improve patient care (NHS, 2019).
Similarly, an independent inquiry chaired by Robert Francis QC found many failures in the quality of care at Mid Staffordshire NHS Foundation Trust resulting in a complete breakdown in fundamental nursing care and in the wider governance. 290 key recommendations were made for healthcare regulators, providers and government to improve services in order to provide safe, high quality health care for all (Francis, 2013).
The Department of Health and Social Care (DHSC) (2016) focusses its drive to continually improve the quality of care whilst also managing the financial sustainability of the NHS. To support this the NHS devised a shared delivery plan known as the Five Year Forward View, their objectives are to reduce costs by £22 billion which will be reinvested in front line services (Gov.UK, 2015). The Quality Innovation Productivity and Prevention (QIPP) programme into how the NHS proposes to make those savings whilst continuing to improve the quality of care the NHS delivers. Arguably, The Royal College of Nursing (RCN) (2012) are concerned that short term savings are at the expense of the long-standing service change needed to meet the challenges of an ageing population, they further describe their concern for the damage it may be doing to patients today and in the future. Similarly, (CQUIN) (2018), more commonly known as Commissioning for Quality and Innovation, is a framework which aims to continually improve quality and drive innovation, it is incentive based to encourage service providers to achieve targets in exchange for financial payment. This system drives forward productivity, beneficial in any establishment.
It is also through continued SI that the NHS has been able to respond successfully to the growing population, the sicker population as well as the ageing population. Statistics show that even with such a growing population the percentage of the general public being satisfied with the NHS has doubled. This has been possible due to the successful implementation of the number of innovative SI programmes. There are also arguments that there has been no healthcare system, anywhere in the world, that has been able to manage even a little growth without cutting down on the numbers of staff or services except the NHS (Allcock et al, 2015).
Various measures have been put in place as a strategy for SI, such measures have been linked with improved care systems in terms of the quality of care and satisfaction of both the service users as well as the healthcare providers. For instance, it is through SI that the NHS has been able to improve dramatically for the last 15 years thus enhancing the quality of care (Allcock et al, 2015). Statistics identify that through SI tailored towards improving the NHS it has led to increased cancer survival (England, 2016). In addition, the level of early death rates due to cardiovascular disease has gone down by approximately 40%. The level of the overall avoidable deaths has reduced by at least 20% following the implementation of the innovative SI in health care. There are also arguments that approximately 160,000 doctors, nurses and other medical staff are now able to treat masses of patients that in the past had to wait for long periods of time for their operations. In fact, the waiting times have reduced from 18 months to around 18 weeks, thus ensuring delivery of care when needed the most, therefore saving lives.
Patient safety plays a prominent role in health care, however, medicine’s vulnerability to error is becoming more apparent. A medical error is described as a preventable adverse effect of medical care according to (Carver and Hipskind, 2018). Assin et al (2015) state the cost of medication errors worldwide has been estimated at 42 billion US$ per year. Similarly, in the UK, researchers found that medication errors cost the NHS £1.6 billion every year (Graien, 2018). Moreover, 1 in 10 hospital patients in the UK suffers unintentional harm due to medical error (NHS, 2013). Children and infants are thought to be most at risk of serious or fatal adverse drug reactions (Avery et al, 2012). The National Patient Safety Agency (NPSA) support this by confirming that children aged 4 years and under were involved in 10.1% of medication incidents within NHS hospitals on almost 60,000 cases. Children’s vulnerability is to some extent due to the significant changes in body proportions and composition that accompany growth and development considering the pharmacokinetic, pharmacodynamic and toxicological parameters between children and young people at various ages and stages of development thus explaining that doses of medicine need to be calculated for each child on an individual basis, In turn, the need for case by case calculation opens the door to errors in terms of not knowing what the correct dose for that child should be (Ghaleb et al, 2010).
Human error cannot be disregarded from the clinical area as it can have serious implications for patient safety, the NHS need to design safer systems to minimise the harmful effects of errors. Shappell and Wiegmann (2014) developed a framework used in many organisations known as The Human Factors Analysis and Classification System (HFACS), its main purpose is to explore and analyse the systems that can result in human error. Their design driven system includes people, technology, products, organisations, and environments. HFACS can be utilised to study historical events to identify reoccurring trends, it looks at organisational impacts, unsafe supervision, preconditions for unsafe acts and unsafe acts, ultimately it will reduce accident and injury rates, (Shappell and Wiegmann, 2014).
According to the World Health Organisation (WHO) (2018), there is a 1 in 300 chance of being harmed during health care, they further state that patient harm is the 14th leading cause of the global disease problem. Moreover, in the United States of America (USA) researchers estimate that medical error is now the third leading cause of death. Makary and Daniel (2016) maintain that medical error does not appear on patient death certificates, this is due to a limitation which relies on conveying an International Classification of Disease code (ICD) to the particular cause of death, consequently, death which has not been associated with a code such as human factors would not be captured, nevertheless they call for improved reporting (Makary, 2016).
Studies further indicate that there have been cases whereby students have been mistaken for qualified surgeons or nurses asked to perform a certain role therefore, putting the patient at more risk (Psnetwork.org, 2019). In their study, Tan et al., (2014) also found out that there are chances of mix-ups in the emergency theatres when there is no better and a quick way of identifying one another. Psnetwork.org (2019) adds that there is the need to use names and role delegation on the caps of healthcare professionals because the practice ensures that there is easy avoidance of common mistakes as well as the poor communication all of which contribute to increasing in adversity events for the patients. According to Dr Hackett who was the first to use and champion the use of names as well as role delegation on caps, this simple measure can decrease human errors thus increasing patient’s safety (Thomas, 2009).
It is evident that there is an increased concern of patient safety, especially during operations (Psnetwork.org, 2019). Studies carried out have confirmed that there has been an increase in health adversity due to wrong identification and incorrect delegation of roles during operations (Thomas, 2009). This problem has prompted some research to provide a remedy to this particular issue of concern. As a result, the strategy of using names and role delegation onto theatre caps has been implemented in different countries across the world. However, some regions still continue to lag behind as far as the implementation of this SI is concerned. This means that there is a need for further research to prove the significance of this SI innovation. Given the surplus of potential problems, there is a clear need to gather robust evidence in errors in a paediatric setting and on innovative approaches to reduce errors amongst children and young people, especially in the theatre departments (Hackett, 2019).
The Aim of the Research
The proposed SI innovation aims to achieve a higher quality experience of care to children than it is currently being achieved by the NHS (Gage, 2013). Studies indicate that it is through SI that objectives of service users are associated to that of the care provided as well as that of the healthcare facility (Sukwadi and Yang, 2014). With this understanding, the main aim of this proposed SI is to determine if patient safety will improve by introducing names and role delegation onto theatre caps in the paediatric theatre.
Prior to the service improvement, a researchable question was identified. This was achieved by exploring the range of the relevant research that is available on the researchable question which is ‘will patient safety improve by introducing names and role delegation onto theatre caps?’. In order to explore the available literature sources on this topic, the scoping review technique was employed. According to Jacobs (2017), the scoping review is known as a focused technique that enables researchers, especially in the field of nursing to examine the emerging evidence on a given area of study. Nonetheless, there are arguments that it is important for researchers, especially in the nursing field to prioritise defining the question of the research using the most suitable framework. Having this understanding, the PICO model (Population, Intervention, Comparison, and Outcome) was employed. According to Patel (2018), the PICO framework is recognised as a focused model that is widely utilised in nursing. It is the best model to use in evidence-based practice.
It is argued that the best approach of obtaining literature materials relevant to the research question is through the application of keywords and phrases to the selected online databases. Although the PICO would be applied, for this research only the PIO elements are used as no ‘C’ comparison is required (Huang et al, 2006).
Not knowing who’s who in the theatre team
Introduce names and role delegation onto theatre caps
Keywords and Phrases used in Literature Search
Safety Reduce error
Patients Role delegation
Names Patient safety
Hats Theatre caps
Communication Role delegation
Having identified the keywords and phrases discussed in table 2, Each word and phrase was applied independently with the aim of increasing the number of search results. Again, the idea behind the application of each keyword and phrase is to increase the chances of obtaining the literature materials that are most relevant to the research topic. Three online databases were used that include CINAHL, Medline, and Cochrane. The reason behind the selection of these databases is because they are well known for providing literature materials that are more relevant to nursing (Silva et al., 2015).
For the purpose of gathering literature materials that are most relevant and can accurately be used to answer the research question, certain criteria had to be considered, the first criteria were that only journal articles published in the previous 10 years could be included. Additionally, only a well-defined research methodology could be considered. Therefore, papers that had been published between 2009 and 2019 were used so that the information used is up-to-date and can be used to inform evidence-based practice. There are arguments that research papers with clear research methodology provide results that are more valid and reliable and can be accurately used (Kumar, 2019).
After applying the keywords and phrases from Table 2 to the online databases, a total of 69 items were obtained. Out of 69 journal articles 35, 22 and 12 items were retrieved from Medline, CINAHL, and Cochrane.
From the 35 articles obtained from Medline, 15 items were published earlier than 2009, therefore was excluded. 12 more articles were also excluded due to the fact they lack a clear research methodology. 4 more articles could not be included because they were found to be published in another language. An additional 3 more articles retrieved from Medline were excluded due to the fact they were found not to have ethical considerations. Finally, one item was found to be legible for this research, therefore was included in the review.
When searching through the CINAHL database 10 articles were excluded because they were published earlier than 2009, An additional 7 articles could not be included due to the fact they are published in a different language. 3 items still could not be included because they lacked clear research methodology and only one was excluded due to failing to meet ethical considerations. One article from CINAHL could meet the criteria.
Out of 12 peer-reviewed journal articles gathered from the Cochrane database, only 1 met the criteria. 5 items were excluded due to being published earlier than 2009. 3 articles lack research methodology thus could not be included in the research. 3 peer-reviewed journal articles were excluded on the basis of being published in a different language. No articles were excluded due to not meeting ethical considerations, Therefore, a total of 3 journal articles were included, one from each of the online search databases.
Service Improvement Intervention
It is evident that there has been harm as a result of inadequate safety of patients (Ramsay et al, 2019). For instance, there have been issues such as death following the wrong blood transfusion as a result of staff misidentification and misunderstanding (Tully et al, 2018). The main reason to blame for increased errors and patient harm in theatre is a lack of clear naming and role delegation to some or all of the practitioners delivering the care (McCulloch et al, 2017). It is with this understanding, that the research identified the idea of implementing names and role delegation onto theatre caps as a suitable approach of improving patient safety and reducing error. This intervention will involve labelling theatre caps in accordance with the name and role of the individual practitioner. By so doing, the identification will be easy in such a way that there will be no room for misidentification or misunderstanding. Easy and accurate identification will then save on time, reducing errors and improving patient safety.
The research used will adopt a survey whereby the respondents will be required to answer a focussed question ‘will patient safety improve by introducing names and role delegation onto theatre caps?’, this will be administered through a questionnaire. It will also include a comments box to give respondents the opportunity to explain their answer in further detail. Qualitative data will be used for this study as it involves participant observation to gather non-numerical data with the understanding of the issue in question from an individual perspective (Surveymonkey, 2019). This method is beneficial to gain an understanding of the general attitudes of staff in the theatre team. Open-ended survey questions, often in the form of a text box, allow respondents to give a unique answer and the freedom to say exactly how they feel about them.
There are many drivers which push for improvement in healthcare. The PESTLE analysis, an abbreviated form for Political, Economic, Socio-cultural, Technological, Legal and Environmental, Leigh-Hunt (2016) states its objective is to understand about context and to recognise the important links between problem-solving and decision making.
One of the political drivers to consider for this intervention include the NMC code which both qualified and student nurses must adhere to. Similarly, other members of the theatre team include surgeons, which are regulated by the General Medical Council (GMC), likewise the anaesthetist professional body is The Royal College of Anaesthetists (RCOA), ultimately, they all serve the same purpose, to ensure the quality of patient care. Carver and Hipskind (2018) state the high incidence of error with serious consequences are more likely to occur in high intense areas such as emergency departments and operating theatres. Research shows there have been over 70% adverse events in theatre and the entire care delivery that have been associated with communication errors (Psnetwork.org, 2019). According to Jawad and Kantsedikas (2018), there have been over 30% of cases of communication failures amongst the theatre team. This is a significant percentage that resulted in inefficiency as well as increased tension. In addition to the communication failures, there have been cases of staff misidentification that has also contributed to the adversity in healthcare (Psnetwork.org, 2019). For instance, cases of death following the wrong blood transfusion as a result of staff misidentification have been reported. This has been linked with lack of names as well as the role delegation on the caps of practitioners in theatre. One of the great legacies created through ‘Compassion in Practice’ was the 6Cs whereby communication is fundamental to successful team working (NHS England, 2016).
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