Never events: analysis of HSIB's national investigations

From the investigation: Never events: analysis of HSIB's national investigations

Recommendation date:

Safety recommendation

It is recommended that the Centre for Perioperative Care reviews and revises the National Safety Standards for Invasive Procedures (NatSSIPs) policy to increase standardisation of safety critical steps that are common across all procedures.

Response:

The Centre for Perioperative Care has already instituted a NatSSIPs working group with wide membership and clear terms of reference. An initial meeting in January 2021 has occurred. We have started on the plan to review and revise the National Safety Standards for Invasive Procedures (NatSSIPs).

We will seek views on the practicalities of what might work in any clinical setting where invasive procedures are undertaken.

We will review the current NatSSIPs, literature and reports indicating where revision may be required.

We will involve our Board members and advisory group members to identify different perspectives. We aim to produce a revised version of NatSSIPs, in particular with increased standardisation of safety critical steps that are common across organisations.

We will keep HSIB informed of our progress with the work throughout the project. We will consider different audiences and staff groups and whether specific education is required.

We will seek assistance, including from HSIB, with ensuring that our revised NatSSIPs are disseminated widely and used as part of a monitoring framework to assist uptake.

Actions:

  • CPOC to institute a NatSSIPs working group. TIMELINE: Dec 2020 - done.
  • First meeting of NatSSIPs working group. TIMELINE: Jan 2021 - done.
  • Further meetings and electronic consultation on key issues identified in the review of current NatSSIPS. TIMELINE: Jan - Sept 2021.
  • Drafting a revision of NatSSIPs. TIMELINE: 2021.
  • Dissemination plan. TIMELINE: 2021.

Response received on 9 March 2021.

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