Technology to avert clinical ‘never events’

Never events data has shown once again that errors are still occurring too commonly within the NHS. These events are defined as serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented.
The latest data from NHS England revealed that 33 serious incidents that occurred between 1 April and 31 May of this year were designated by their reporters as ‘never events’. On top of this Jeremy Hunt, Secretary of State for Health, recently told the Patient Safety Congress that up to one in 20 hospital deaths in England could have been prevented.

However, there are solutions available, and the publication in May 2014 of the Government’s eProcurement Strategy will serve to increase the rate at which supporting systems are implemented across the NHS, helping to reduce the likelihood of avoidable errors occurring.

Linking the supply chain
It is estimated that trusts can save £1.5 billion by the end of 2015-16 through taking a cohesive approach to procurement‑based on global standards, national infrastructure and local delivery. The eProcurement Strategy sets out what trusts must do to achieve this and one of the key pillars it identifies is the adoption of GS1 standards, which are now mandated.
According to management consulting firm McKinsey, the adoption of a single global supply chain standard across the entire healthcare supply chain could save up to 43,000 lives and avert 1.4 million patient disabilities globally.

Achieving widespread adoption of GS1 standards throughout the NHS requires new systems and processes to be rolled out and will bring challenges for trusts, yet the barcoding and electronic tagging technologies it commonly uses are already prevalent in other industries such as retail.
Consider the grocery sector for example. Most people are familiar with automated checkouts in supermarkets and the warning ‘unexpected item in the bagging area’. This technology, which enables the till to know where each item is and whether it has been properly accounted for, can also be applied to theatre environments where it can help prevent many surgical and medicinal never events.

Adopting a new approach
The process of using instruments in operating theatres is clearly prone to human error, with 123 of the 312 never events reported in the year 2013/14 data being instances of items wrongly left inside patients. With thorough identification and tracking technology in place, the risk of this type of events happening can be greatly reduced.
Similarly, serious medication errors are common in hospitals and often occur during order transcription or administration of medication. An additional layer of safety is provided through the use of barcodes, which sees medication tracked from when it is first prescribed, through dispensing to the point at which it is administered to the patient. Furthermore, warnings can flag to healthcare providers when medicine is overdue, may interact with other medicines the patient is taking, or does not match the prescription. Preliminary studies have suggested that the use of barcodes on medicines to the single unit level can help to reduce medication error rates by 41.4 per cent.

While GS1 standards being mandated is a new development, the use of the standards in hospitals is not. They are already in evidence to some extent in most hospitals, sometimes without that trust necessarily realising it. As such, each trust is at a different level of adoption and some are already seeing benefit from the impact the supporting technology can have on improving patient safety.

Tracking products
Every hospital stocks a vast array of equipment which is stored, accessed, used, cleaned and replaced in a very busy environment. When manual processes underpin this activity, it is clear to see how mistakes and oversights can happen.
At the Southport & Omskirk Hospital NHS Trust, all medical instruments are tagged using unique, trust-specific identification numbers which are held on a database. By linking the tags to a tracking system it is possible to capture a huge amount of data including the time and date the instrument was used, when it was washed or decontaminated and where it was moved to afterwards. This is all achieved through simple scanning at each point in the process.
Tagging or marking each item enables the linking of individual instruments, medicines and implants to the patient on which they were used. All of this data makes quick tracking of products possible for incidences when the need to identify or even recall instruments becomes necessary.

Tracking patients
Since October 2013 it has been a required standard (NHS ISB 1077) for NHS hospitals in England to issue patients with printed wristbands bearing a GS1 DataMatrix bar code, which is smaller than standard bar codes but can contain far more information.
This identification wristband provides quick access to a patient’s electronic health record through a bar code scan, enabling health workers to confirm identification before drugs are dispensed and to uniquely allocate any instruments used for implants given to that patient.
Sherwood Forest NHS Foundation Trust met the requirements of the standard through the implementation of a patient identification system across all its wards. The trust now has 100 per cent wristband coverage, including in the paediatric and maternity units, where the new solution enables the creation of smaller wristbands  that still contain all the required information.
From the patient’s perspective, this change has been far from disruptive with those that had used the previous wristbands not noticing any difference. Many end users however, particularly those in the paediatric unit, were impressed with how much information can now be fitted onto such a small space and how much clearer it is. The real benefit to the trust is that the solution significantly cut the risk of patients being misidentified on the wards and receiving incorrect treatment.

Tracking medical records
Locating a patient’s medical record can be a frustrating and time-consuming process, with nurses sometimes wasting a significant portion of their shifts on such tasks as patients move between wards and clinics and their file gets misplaced.
To solve this issue, Royal Bolton Hospital implemented Radio Frequency Identification (RFID) tags on its medical records. RFID uses radio waves meaning that single or multiple tags can be read almost simultaneously without the tags needing to be in the reader’s line of sight.
In the year leading up to the implementation, 0.14 per cent of requested records were found to be ‘missing’ and the work required to search for them was equivalent to 2.54 FTE (full time equivalents) within the medical records department. In addition, eight per cent of records that were requested were not found in the exact location (displayed on the system) and the additional time spent searching for them was equivalent to 0.64 FTE.
After studying their existing processes, Royal Bolton anticipated that: the time spent looking for misfiles would be reduced by 80 per cent; the average time taken to locate a missing file would be reduced by 92 per cent; and that by decreasing the time to find misfiles and missing files, lost revenue due to coding time-outs would be decreased by 64 per cent (£230,000 per annum).

Time for technology
The healthcare industry is, perhaps understandably, behind many other industries when it comes to embracing digital systems and solutions, but the NHS faces many challenges that have to be overcome if it is to continue in its current form and technology has a big role to play in achieving that.
As an industry we cannot afford to let never events continue when there is a simple solution available. GS1 standards are already mandated within the healthcare sector to improve procurement efficiency and reduce costs. The rollout of the same technologies in operating theatres could help to improve patient safety, so what are we waiting for?

Further information

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