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Journal of Perioperative Practice

PROCUREMENT GUIDE November 2016 01423 881300

Volume 05 Issue 05

Journal of Perioperative Practice cover 18/10/2016 10:17 Page 1

01423 881300

2% CHG / 70% IPA didn't cut SSIs by 41%


ChloraPrep did ®


* compared with povidone iodine



Patient Preoperative Skin Preparation 2% chlorhexidine gluconate (CHG) & 70% isopropyl alcohol (IPA) For customer services and all other enquiries please telephone 0800 917 8776, email or visit Prescribing Information: ChloraPrep & ChloraPrep with Tint 2% chlorhexidine gluconate w/v / 70% isopropyl alcohol v/v cutaneous solution. Refer to the Summary of Product Characteristics before prescribing. Presentation: ChloraPrep – each applicator contains 0.67ml, 1.5ml, 3ml, 10.5ml or 26ml of 20 mg/ml chlorhexidine & 0.70 ml/ml isopropyl alcohol; ChloraPrep with Tint – each applicator contains 3ml, 10.5ml or 26ml of 20 mg/ml chlorhexidine & 0.70 ml/ml isopropyl alcohol. Indication: Disinfection of skin prior to invasive medical procedures. Dosage & administration: Applicator volume dependent on invasive procedure being undertaken. May be used for all age groups and patient populations. Use with care in newborn babies and those born prematurely. Applicator squeezed to break ampoule and release antiseptic solution onto sponge. Solution applied by gently pressing sponge against skin and moving back and forth for 30 seconds. The area covered should be allowed to air dry. Contra-indications: Patients with known hypersensitivity to ChloraPrep or ChloraPrep with Tint or any of its components, especially those with a history of possible Chlorhexidine-related allergic reactions. Warnings and precautions: Solution is flammable. Do not use with ignition sources until dry. Do not use in excessive quantities, allow to pool in patient skin folds or drip on materials in contact with patient skin. Remove any soaked materials before proceeding with the intervention. Ensure no excess product is present prior to application of occlusive dressing. For external use only on intact skin, do not use on open skin wounds or broken or damaged skin. Over-vigorous use on fragile or sensitive skin or repeated use may lead to local skin reactions. Avoid prolonged skin contact. Avoid contact with eyes, mucous membranes, middle ear and neural tissue. Chlorhexidine may induce hypersensitivity, including generalised allergic reactions and anaphylactic shock. May cause chemical burns in neonates, with a higher risk in preterm infants and within the first 2 weeks of life. Pregnancy & lactation: Although no studies have been conducted, no effects are anticipated ®

Reference: 1. Darouiche R et al. N Engl J Med 2010; 362: 18–26. ©2016 BD. BD, the BD Logo and all other trademarks are property of Becton, Dickinson and Company. Date of preparation: May 2016. 0000CF02841 Issue 1

as systemic exposure is negligible. Undesirable effects: Very rare; allergic or irritation skin reactions to chlorhexidine, isopropyl alcohol or sunset yellow (E110, present in ChloraPrep with Tint only), including erythema, rash, pruritus and blisters or application site vesicles, other local symptoms have included skin burning sensation, pain and inflammation. Frequency not known; hypersensitivity including anaphylactic shock, dermatitis, eczema, urticaria, chemical burns in neonates. Discontinue use at the first sign of local skin reaction. Per applicator costs (ex VAT) ChloraPrep: 0.67ml (SEPP) - 30p; 1.5ml (FREPP) - 55p; 1.5ml – 78p; 3ml – 85p; 10.5ml - £2.92; 26ml - £6.50. ChloraPrep with Tint: 3ml – 89p; 10.5ml – £3.07; 26ml £6.83 Legal category: GSL Marketing Authorisation Numbers: ChloraPrep, PL31760/0004 & ChloraPrep with Tint, PL31760-0001 Marketing Authorisation Holder: CareFusion UK 244 Ltd, The Crescent, Jays Close, Basingstoke, Hampshire, RG22 4BS. Date of Preparation: February 2016 Reporting suspected adverse reactions is important to monitor the benefit/risk balance of the medicinal product. Reporting forms and information can be found at yellowcard. Adverse events should also be reported to CareFusion Freephone number: 0800 0437 546 or email:


Journal of Perioperative Practice PROCUREMENT GUIDE November 2016 Volume 05 Issue 05


Welcome to your November 2016 Guide 04 On the cutting edge of the Sharps Directive

08 Comedy of Errors not

a laughing matter! – Never Events review

14-19 Product News: 14 Laprosurge 14 Teleflex

14 Medline 15 PROACT Capnograph 16 PROACT Professional Laryngoscopes

17 PRO-Breathe® Airway Management from PROACT Medical

17 Detergent choice from schülke

18 Wardray Premise

appointed as a distributor of the IV-eye® vein imager

19 VacSax

Journal of Perioperative Practice Procurement Guide information In print within the AfPP Journal of Perioperative Practice covering national AfPP members, but also with a dedicated print and e-distribution to supplies and purchasing managers. Key Sectors: NHS Supply Chain, Independent Hospitals, Higher Education. Medical Device Companies. Published 6 times a year we will focus on procurement issues in every edition as well as specialist subjects which for the following year include:

January 2017 Patient Warming/ Patient Monitoring March 2017 Medical Instruments/Devices/ Equipment/Laparoscopic & Endoscopic Instruments May 2017 Infection Prevention/Infection Control/Decontamination/Clinical Waste/Wound Management

Contact Information: Advertising, Sponsorship & Partner Packages Frances Murphy Account Manager Open Box M&C T: 0121 200 7820 E: Editorial Chris Wiles Head of Publishing/Editorial AfPP T: 01423 882950 E:

PR & press material. All press releases welcome and we will feature as many as we can in each issue, all press releases need to be submitted to: Frances Murphy Account Manager Open Box M&C T: 0121 200 7820 E:

Front cover image ©Swann-Morton


Journal of Perioperative Practice PROCUREMENT GUIDE November 2016 Volume 05 Issue 05


On the cutting edge of the Sharps Directive

The recent inspection report issued by the Health and Safety Executive (HSE 2016) concluding that out of a sample of 40 audited organisations 83% displayed breaches in the Sharps Regulations, probably adds to the confusion which still surrounds the interpretation and implementation of the Sharps Directive throughout the healthcare sector both here in the UK and Europe. In addition to this most of the studies published to date surround needle stick injuries so where do scalpel and blade related injuries sit in relation to the wider picture? Research studies show that sharps injuries could range between 800,000 and 5,120,000 per year for healthcare workers in Europe (Weber 2013). Seven to 11% of the injuries can be attributed to scalpels and blades (Centre for Disease Control and Prevention 2015) and the

majority of sharps injuries occur amongst nurses (Fuentes et al 2008). The incidence of scalpel blade injuries are actually higher than disposable syringes and loose needles when compared to respective volumes; 662 scalpel incidences / 100,000 used vs. 3.2 syringe and loose needles incidents / 100,000 used (Eisenstein & Smith 1992). In the operating theatre scalpel blade injuries are the second most common sharps injury after suture needles (Jagger et al 1998).

Swann-Morton continue to run in house training initiatives in respect of scalpels and blades supported by accompanying AfPP endorsed materials and a suite of state of art training films available on their website. Hopefully this will assist staff in unravelling the mysteries of the directive and make those decisions that are needed within their own area of specialty the move towards compliance. What is right for general theatres may not be right for plastics and what one may feel is suitable for maternity just won’t be practical in orthopaedics. There is no perfect fit, there is no one size fits all and there are no shortcuts to making what is a complex decision that impinges on staff and patients alike. It is three years since SwannMorton’s customer support team went out to hospitals offering training in best practice when handling surgical blades and scalpels across a variety of healthcare settings. Already active in training ODPs within Universities it was decided to try and roll out a similar programme to experienced staff in an attempt to create awareness as to the various safety solutions that were available and to refresh them on best practice techniques for fitting and removing a surgical blade from the handle.

A reminder to more senior staff that one should not be using one’s fingers for this process tends to be met with some surprise, “I have been doing this job for 40 years and I have never had a sharps injury”. However, they recognise that we are making a valid point when considered within the context of the directive. They must also realise that they are the role models and opinion leaders to whom the next generation looks up to so this is an invaluable opportunity to lead their team by example and it is refreshing to hear such comments as “I will do all I can to protect my nurses and keep them safe”. It was over 25 years ago when Swann-Morton first launched their single use sterile blade remover to be used in the safe removal of the contaminated sharp from the handle at the point of the procedure. The blade, safely encapsulated within the unit, is still visible through the transparent remover for the final count before being disposed of in a sharps container. “We shall never be able to justify using this remover” and “it shall double our costs” were typical replies received from staff, yet over this period the product was adopted in many theatres across the country even before the recent surge in demand driven by the directive. This product may be seen as the


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Journal of Perioperative Practice PROCUREMENT GUIDE November 2016 Volume 05 Issue 05

>> best compromise between the surgeon and the surgical team: the surgeon still gets to use the beloved metal handled scalpel and the nurses get the protection from the contaminated sharp during removal and disposal. The development of a retracting safety scalpel with one our US associates in the late 1990s gave SwannMorton early exposure to the OSHA (Occupational Safety and Health Administration) initiatives and ultimately the legislation over in the United States, which was to raise awareness of needle stick and sharps injuries across the medical world. Again the company was early to market with just three sizes of blades, 10, 11 and 15, regarded by many at the NATN/AfPP show in Harrogate as a “craft knife” or something destined for the “sewing basket”. How times change and even before the Directive was adopted into law in May 2013 increasing enquiries resulted in the range being extended to include larger size blade shapes 20 to 25a which now regularly appear on tender across Europe. Targeting what they perceive as “high risk” areas such as maternity, A&E and the wards the HSE, in our experience, are looking to convert standard scalpels over to safety versions in all these areas. The more recent addition of the safety stitch cutter has been very well received given that traditionally this blade was held in the fingers whilst removing the sutures. Off the cusp of the adoption of formal sharps legislation as part of the Health and Safety at Work act came the evolution of the “cartridge” or “blade management” system. Surgeons in the USA had already dismissed the plastic handled safety scalpels as being too light for general procedures leading to the development of blades contained within a protective

Sharps cartridge that fitted a metal scalpel handle thus providing the balance and stability the surgeons needed to sustain their patient outcomes whilst offering protection from the sharp both when mounting and removing the blade from the “specially designed handles”. A number of UK hospitals trialled the US systems and although they liked the concept the need to swop out all the surgical handles was both a financial and administrative burden they did not need. The fact they did not carry a SwannMorton blade also became an issue so when asked if we were launching a similar system we took the decision to precede with a concept that had been presented to us several years earlier. The difference with this system was the cartridge would fit the standard surgical handles already in circulation and “KLEEN” was born. Throughout the UK trials carried out on KLEEN there has been a general appreciation from the theatre team of the protection it offers them from potential sharps injuries. However it is not appropriate for all areas of surgery. The retracting sheath can alter the tactile feel of the handle especially when undertaking delicate procedures requiring additional dexterity and control of the scalpel. The protective sheath once retracted down the handle can obscure the surgeon’s line of vision especially in deep surgeries whilst for minimal invasive techniques again it adds unwanted girth to the scalpel. On the positive side there has been a general acceptance that KLEEN could be used as the skin knife with the blade sheath distinguishing it from the other scalpels being used during the procedure. We have also observed it being used successfully in a number of surgical disciplines including gynaecology, hernia repair and colorectal. Believe it or not a number of the surgeons differ in their opinions even

when working within the same disciplines so the resistance to change is ever present. Having recently been unveiled as the new UK distributor of the Qlicksmart safety products, which will form a natural extension to the existing range of Swann-Morton sharps safety solutions, the company is now able to assist in improving patient and staff safety in both acute and non-acute healthcare settings. The single use blade remover, retractable safety scalpels and the KLEEN blade management system are now joined by a Qlicksmart range which features Blade FLASK, Blade SINGLE, Blade CASSETTE and the BladeNeedleSYSTEM offering simpler safer ways of removing and disposing of contaminated blades after use. Snap-IT an easy-to-use multiuse ampoule opener is helping avoidance of the unacceptable sharps injury rates seen when ampoules are opened by hand, avoiding painful and dangerous sharps injuries, also comes in house. Twenty-six percent of sharps injuries can be attributed to broken ampoules (Smith & Leggat 2005) and 54% of sharps injuries within an anaesthesia setting are ampoule related (Pulnitiporn et al 2005). So, as mentioned earlier, there is no simple or single solution to achieving compliance. However, by undertaking the relevant training and education, thus making staff aware of the options available to them, they are in a better position to risk assess their own working environment and make the informed decision which may protect both themselves and their colleagues from a serious sharps injury without compromising their patients. For more information please contact Swann-Morton Limited by email on

References and further reading Centre for Disease Control and Prevention 2015 Sharps Injury Prevention Workbook [online] sharpssafety/index.html [Accessed October 2016] Eisenstein HC, Smith DA 1992 Epidemiology of reported sharps injuries in a tertiary care hospital The Journal of Hospital Infection 20 (4) 271-80 Fuentes H, Collier J, Sinnott M, Whitby M 2008 “Scalpel safety”: Modeling the effective-ness of different safety devices’ ability to reduce scalpel blade injuries International Journal of Risk and Safety in Medicine 20 (1-2) 83-89 Health and Safety Executive 2016 Prevention and management of sharps injuries: Inspection of NHS Organisations [online] healthservices/needlesticks/ prevention-management-sharpsinjuries.pdf [Accessed October 2016] Jagger J, Bentley M, Tereskerz P 1998 A study of patterns and prevention of blood exposures in OR personnel AORN Journal 67 (5) 979-81, 983-4, 986-7 passim Pulnitiporn A, Chau-in W, Klanarong S, Thienthong S, Inphum P 2005 The Thai Anesthesia Incidents Study (THAI Study) of anesthesia personnel hazard Journal of the Medical Association of Thailand 88 Suppl 7 S141-4 Smith DR, Leggat PA 2005 Needlestick and sharps injuries among nursing students Journal of Advanced Nursing 51 (5) 449-55 Weber T 2013 Promotion and Support of Implementation of Directive 2010/32/EU on the prevention of sharps injuries in the hospital and health care sector. Final Report (on behalf of HOSPEEM) [online] http:// article/files/Final-Report-ICFGHK-15-11-13-EN_TW-3.pdf [Accessed October 2016]

JPP_138x188_sharps_BMS_NOV 04/10/2016 16:13 Page 1


in mind first time, everytime In response to the EU Sharps Directive 2010/32/EU Swann-Morton have launched the KLEEN Blade Management system consisting of their standard blade enclosed within a protective cartridge thus supporting safe handling when fitting and removing the blade from your existing surgical handles. Complimented by Retractable Safety Scalpels, single use Blade Removers and “Cygnetic” they can now offer a complete range of compliant safety solutions. Swann-Morton can offer in house sharps safety training in line with the new Directive so contact us on sharpssafety@ for more information. For more information on the complete range of surgical blades, handles, scalpels, disposable, fine and retractable scalpels please go to our website.

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Journal of Perioperative Practice PROCUREMENT GUIDE November 2016 Volume 05 Issue 05

Never Events

Comedy of Errors not a laughing matter! - Never Events review “A wretched soul, bruised with adversity, We bid be quiet when we hear it cry; But were we burdened with light weight of pain, As much or more we should ourselves complain.” William Shakespeare, The Comedy of Errors Whilst chairing a session at our recent residential event at York University my wife, Anne, sent me this image taken from that days Times newspaper (Figure 1). Only a short passage, tucked away in the foreign news section of the paper, but significant enough for Calum MacLeod to forward his report to his editor! Read it for yourself and reflect upon what has actually gone wrong in this comedy of errors for the waiting relative? • Misunderstanding • A breakdown in communication • Assault and battery

• Mistaken identity • Pain and suffering • Loss of dignity • A break in protocol... Could this Never Event happen: • In the department where you work? • To the team of which you are a member? • Have you been involved in a never event in the last year? Of course it could and does! In September last year the National Safety Standards for Invasive Procedures (NatSSIPs) was published by the NHS England Patient Safety Domain (NHS England 2015). Section from Preface (p5): “These NatSSIPs are intended to provide a skeleton for the production of Local Safety Standards for Invasive Procedures (LocSSIPs) that are created by multiprofessional clinical teams and their patients, and are implemented against a background of education in human factors and working as teams. The NatSSIPs do not replace the WHO Safer Surgery Checklist. Rather, they build on it and extend it to more patients undergoing care in our hospitals. They will standardise key elements of procedural care, ensure that care is harmonised – not just within organisations delivering NHS-funded care but also between organisations – and will reinforce the importance of education to patient safety.”

Figure 1 The Times, 12 August 2016

Dr Mike Durkin Director of Patient Safety NHS England

To whom doth read this mortal tome! • Have you and your colleagues had the opportunity to read this important document? • Has the production of your local standards for invasive procedures been produced yet? • If they have are you fully aware of your responsibilities in delivering safe surgical outcomes? To help you on your safety journey here are a few reminders from this important document’s text: Never Events (p11) Never Events are a particular type of serious incident that meet all the following criteria: • They are wholly preventable, where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level, and should have been implemented by all healthcare providers. • Each Never Event type has the potential to cause serious patient harm or death. However, serious harm or death is not required to have happened as a result of a specific incident occurrence for that incident to be categorised as a Never Event. • There is evidence that the category of Never Event has

occurred in the past, for example through reports to the National Reporting and Learning System (NRLS), and a risk of recurrence remains. • Occurrence of the Never Event is easily recognised and clearly defined – this requirement helps minimise disputes around classification, and ensures focus on learning and improving patient safety. Why do Never Events happen? (p11-12) No one goes to work to make a mistake To try and understand why Never Events happen, it is necessary to take a systematic and wide ranging approach to the analysis of each incident. One way to understand the underlying influences on human behaviours that can lead to error is to apply a clinical human factors perspective. This means enhancing clinical performance through an understanding of the effects on human behaviour of teamwork, tasks, equipment, workspace, culture and organisation, with the application of that knowledge in clinical settings. Reviews of instances of wrong-site surgery have identified contributory factors that include: • Workspace and environment. • Work design. • Organisation and culture. • Task factors. • Communication. • Policies and procedures.


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Journal of Perioperative Practice PROCUREMENT GUIDE November 2016 Volume 05 Issue 05

>> However, non-technical skills that include cognitive and social ability are also important. Most analysed incidents involve a combination of technical and non-technical factors. Human factors experts have concluded that many of the causes described in investigation reports cannot be adequately addressed by the resulting action plans that target each individual cause. Instead, the causes should be seen as a reflection of the current state of safety within an organisation, showing the underlying cultural and systems issues that need to be addressed at a wider level than that of the incident itself. Further, the response to new safety incidents should not be new policies and procedures, but the simplification and standardisation of existing policies, making sure that they are directly relevant to the areas in which they are used. While team members may have perfect technical skills to perform the procedures, it is often failures in the nontechnical skills that contribute to Never Events. Non-technical skills are ‘the cognitive, social and personal resource skills that complement technical skills and contribute to safe and efficient task performance’.

Never Events • Leadership: not demonstrating procedural compliance, such as using the checklist; not ensuring the whole team had a shared awareness of the task.

• Using electromagnetic radiation (which includes X-rays, lasers, gamma-rays and ultraviolet light) - for example, using a laser to treat eye problems.

• Coping with stress: not dealing effectively with work pressures; requiring staff to work faster.

In using a different term - “invasive procedure” – NatSSIPs proposes to address those procedures that have the potential to be associated with a Never Event if safety standards are not set and followed, to include:

Non-technical skills are taught in a number of safety-critical industries, most notably aviation, where this was first introduced in the form of Crew Resource Management (CRM) courses. Firstly, the relevant nontechnical skills need to be identified, and then a training course is designed to improve understanding of the skills and to explain how they can influence safety and efficiency. These are usually classroom-based courses with exercises, demonstrations and opportunities for structured practice and feedback. What are invasive procedures? (p14-15)

• All surgical and interventional procedures performed in operating theatres, outpatient treatment areas, labour ward delivery rooms, and other procedural areas within an organisation. • Surgical repair of episiotomy or genital tract trauma associated with vaginal delivery. • Invasive cardiological procedures such as cardiac catheterisation, angioplasty and stent insertion. • Endoscopic procedures such as gastroscopy and colonoscopy.

These include:

The National Institute for Health and Care Excellence (NICE) defines an “interventional procedure” as a procedure used for diagnosis or for treatment* that involves:

• Situation awareness: not gathering enough information; overlooking anomalies; not checking mental pictures with others; not recognising increased risks.

• Making a cut or a hole to gain access to the inside of a patient’s body - for example, when carrying out an operation or inserting a tube into a blood vessel, or

• Decision-making: proceeding with the task rather than checking when uncertain; an over-reliance on assumptions as to correct location such as prepositioned patients.

• Gaining access to a body cavity (such as the digestive system, lungs, womb or bladder) without cutting into the body - for example, examining or carrying out treatment on the inside of the stomach using an instrument inserted via the mouth, or

Your place in the team is now also defined in a new Glossary (p16)

*NICE interventional procedures guidance: about/what-we-do/our-programmes/ nice-guidance/nice-interventionalprocedures-guidance

• Procedure, to include surgical operations, invasive cardiological procedures, endoscopy, interventional

• Teamwork: failures in the team to speak up when the checklist was not followed; inadequate exchange of information to ensure a shared understanding of what was to be done.

• Interventional radiological procedures. • Thoracic interventions such as bronchoscopy and the insertion of chest drains. • Biopsies and other invasive tissue sampling.

In order to extend the remit of invasive procedures to those performed outside of the operating theatres; this document uses the following terms:

radiology, thoracic procedures and biopsies. • Procedure area, to include the operating theatres, cardiac catheter laboratories, endoscopy suites, labour ward and radiology department. • Procedure room, to include the individual procedural venue, e.g. operating theatre, delivery room and endoscopy room. • Procedure team, to include all those involved in the performance of the procedures, including doctors, nurses, midwives, operating department practitioners (ODPs), healthcare assistants (HCAs), technicians, scientists and any others directly involved in the performance of the procedure. • Operator, to include the surgeon, endoscopist, cardiologist, obstetrician, midwife, radiologist or other healthcare professional or practitioner performing the invasive procedure. • Senior operator, to imply the clinician with overall responsibility for the procedure. • Operator team or clinical team, to include the surgical or other team planning, scheduling and delivering care for the patient undergoing an invasive procedure. • Operator’s assistant, to include any healthcare professional acting as first assistant to the operator. • Scrub practitioner, to include any healthcare professional taking the role of what would be traditionally held to be a “scrub nurse” in the operating theatre, i.e. managing the equipment and instruments during a procedure, ensuring sterility and participating in the reconciliation of swabs, needles, instruments and other items.


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Journal of Perioperative Practice PROCUREMENT GUIDE November 2016 Volume 05 Issue 05

>> As an opportunity, review the following case studies from the report, make notes on what went wrong and why, and reflect on how you would have felt as a member of the perioperative teams involved? Sabeena’s story (p22) Sabeena is a 36-year-old woman suffering from advanced endometriosis. It was agreed that the best course of treatment for Sabeena would be the removal of her ovary, fallopian tube and uterus, which could be performed laparoscopically. Because of her age, she was keen to preserve one of her ovaries so that she would not require hormone replacement therapy. Sabeena consented to total laparoscopic hysterectomy and left salpingo-oophorectomy, with excision of endometriosis and adhesiolysis if necessary (removal of the uterus, cervix, left ovary and fallopian tube, along with treatment for adhesions and scarring). It was agreed that the right ovary and fallopian tube would be preserved, as the left ovary was more affected by the disease. The consent form was completed correctly and Sabeena mentioned to the anaesthetist during the “Sign In” that she was only having one ovary removed. The printed theatre list stated the procedure as “Total laparoscopic hysterectomy + LSO + excision of endometriosis”. As this was complex surgery, the procedure was carried out by an experienced consultant gynaecologist who specialises in treating severe endometriosis, supported by a specialist registrar. The registrar attended the briefing, participated in the Time Out and started the procedure. However, he experienced

Never Events problems inserting the Verres needle (a small needle inserted near the umbilicus that allows gas to be introduced into the abdomen), and asked the consultant to assist him. The consultant joined the theatre team and began the procedure. There were problems with the light leads and camera stack, and it took a few minutes to find replacement equipment, during which time the registrar, who was on call for the wards, had to leave the theatre to answer his bleep. By the time the consultant restarted the procedure, most of the team present at the briefing were not in the theatre: the circulating practitioner was outside looking for equipment, the HCA was working in another theatre that was shortstaffed, and the registrar was on the ‘phone in the corridor. With a new camera stack that was working properly, the consultant continued with the procedure, but started by dividing the blood supply to the right ovary. He quickly realised his error, stopped the operation and informed the procedural team. The surgeon considered saving the left ovary, but felt this was not possible due to the endometriosis, and carried on with the procedure, as it was felt to be in Sabeena’s best interests. Sabeena was told the next day that she had had both of her ovaries removed and received a full explanation and an apology from the surgeon. Although she understood what had happened, she was upset that she would have to take hormone replacement therapy and asked that a full enquiry be conducted and changes made so that the mistake could not happen to other patients. The hospital conducted a Serious Incident enquiry as required by the organisation’s Never Events policy and made changes based on the root cause analysis that is part of the enquiry.

Juan’s story* (p32-33) Juan is a 68-year-old man who underwent a total hip replacement. The surgical team who cared for him work together regularly and are strong supporters of the Five Steps to Safer Surgery. During the Safety Briefing, the hip implant sizes were discussed. The implant consists of three components: socket (inserted into the pelvis), stem (inserted into the femur) and head (placed on top of the stem). Each component is packed separately in its own labelled box. Each component can be of a different size to suit the patient, and each has specific measurements. However, the head has two measurements: the head diameter, which must fit snugly with the socket component, and the length, which is an independent variable. One combination of these implant sizes was considered most likely to suit the patient, but another was brought into theatre as a contingency. The surgeon made the final size decisions regarding size during a visual examination after the start of surgery. She was passed the correct size socket, which she put in place. When ready for the head of the implant, the surgeon asked for a “+5” - a reference to the length, not the diameter of the head. The diameter is not normally specified at that point as it is automatically defined by the size of the socket, which has already been implanted by that time. It was seen as a given by all involved. The circulating practitioner passed the head to the scrub practitioner, who confirmed the length as “+5” but did not read out the diameter. The surgeon assumed that she was being passed a head that matched the socket, but this was not the case – the socket and head were different diameters. The operation was completed; the sticker from the implants was attached

to the operation notes and entered into the computerised national register. The error came to light about a year later when the patient was reviewed in the outpatient clinic. He reported some discomfort and looseness of the joint when walking downstairs. While investigating the possible causes, the surgeon reviewed the operation notes. She noticed that the implant stickers showed that the diameters of the socket and the head were not compatible. The surgeon disclosed the error to the patient and apologised, in line with the Duty of Candour. The patient was upset and unhappy. The team felt devastated that their error had caused harm, especially given the high priority they place on safety in their practice. * Adapted from a story in the NHS England Never Events Taskforce Report

Please find comments on these reports for you to compare with your own on the next page.

Conclusion Never Events are never a comedy; but very personal sagas for patients and staff. This has only been a short review of some of the salient points from this ongoing patient safety education programme, which your Association fully supports. Adrian Jones Vice President AfPP

References NHS England patient Safety Domain 2015 National Safety Standards for Invasive Procedures (NatSSIPs) [online] available from www.england. [Accessed October 2016] MacLoud C 2016 New father given piles op by mistake London, The Times, 12 August 2016 edition

Case studies - Comments from the NatSSIPs Group Sabeena’s Story (p23): “This is a really unfortunate case and, although it is good that Sabeena received a quick and full apology, in line with the Duty of Candour, several errors were made that should not have occurred: • The operating list should not have contained any abbreviations such as “LSO” – this should have been written out in full as: “Left salpingo-oophorectomy”. • The senior operating surgeon who was going to do the procedure should have been present at the Briefing and Time Out.

• The registrar should not have had other commitments that may take him out of the operating theatre during a procedure. • Staff shortages should not lead to procedural teams changing during a list. • If the procedural team changes during a case, a handover should be performed that includes reconfirming the planned procedure and a discussion of any issues raised at the Briefing, Sign In and Time Out.” Juna’s Story (p33): “It is wholly understandable that Juan is upset by the procedural team’s mistake. He

would naturally have expected to have compatible components inserted and will not have understood why he had a socket and head that didn’t match. Analysis of the incident showed that the circulating practitioner thought the scrub practitioner would check the diameter of the head, the scrub practitioner thought the circulating practitioner had checked it, and the surgeon thought the scrub practitioner had checked it. In practice, no one had checked it. The surgeon genuinely thought she was being passed the correct component. Three points are worth making: • The procedural team rightly used the Safety Briefing to discuss the range of implants that would be needed.

Never Events

• The Prosthesis Verification Standard suggests that once the prosthesis has been selected, any prostheses not to be used for that patient should be clearly separated from the correct prosthesis. In this case, two sets of components were retained in the operating theatre, and this may in part have led to the mistake. • The procedural team’s standard procedures did not identify which member of the team was going to check all the characteristics of all three components. The Prosthesis Verification Standard suggests that the operator should confirm all the characteristics of the prostheses with the rest of the procedural team before removing them from their packing prior to their insertion.”

Journal of Perioperative Practice PROCUREMENT GUIDE November 2016 Volume 05 Issue 05



Journal of Perioperative Practice PROCUREMENT GUIDE November 2016 Volume 05 Issue 05

Product News A global trend towards reduced incision laparoscopy LaproSurge is proud to announce an improved and expanded range of high quality reduced diameter instruments for access through 3mm trocars. This comprehensive range enables surgeons to perform less invasive surgery through smaller incisions without a compromise on instrument strength or rigidity. 3mm laparoscopy provides many undeniable clinical and cosmetic advantages without requiring the surgeon to alter operating technique. Accessing the abdominal cavity through 3mm ports has both the cosmetic benefit of reduced skin scarring and the clinical benefits of a reduced level of tissue damage, port-site herniation and wound infection, faster recovery and a reduction in pain scores.

How can a 2.9mm device deliver 5mm performance? Percutaneous insertion! With just a 2.9 mm shaft, Percuvance Percutaneous Surgical System from Teleflex has been engineered to reduce trauma for your patients, maintaining the performance of a 5 mm laparoscopic device. Percuvance introduces a breakthrough form of minimally invasive surgery: percutaneous laparoscopy. Using this approach, laparoscopic devices can enter through a small skin incision without trocars.

Your patients benefit from reduced trauma. You get the versatility and strength of a traditional laparoscopic device. With the Percuvance System, minimally invasive surgery has now been reimagined– making it even less invasive. Mob: +44 (0)7739 628969 Tel: +44 (0)1494 532761 Email: Web:

Teleflex, Grosvenor House, Horseshoe Crescent, Old Town Beaconsfield, Buckinghamshire HP9 1LJ

LaproSurge is already seeing huge success for the 3mm instrument line in gynaecology, paediatric and general laparoscopy throughout the UK, Western Europe and the Middle East. Email: Tel: 01923 220 711 products/3mm-laparoscopy


Medline manufactures and distributes a vast range of medical and surgical products to healthcare institutions and retail markets around the globe. Today Medline Industries, Inc. is the largest privately held manufacturer and distributor of healthcare products in the U.S. and is leveraging that success in international markets.

Founded in 1910, Medline has grown from a small manufacturer of aprons, surgical gowns and uniforms to a thriving $8 billion global enterprise because of our dedicated people, entrepreneurial spirit and honest values. To learn more about our products and company, please visit our website at


Journal of Perioperative Practice PROCUREMENT GUIDE November 2016 Volume 05 Issue 05

Product News

PROACT Capnography and Pulse Oximetry Monitors from PROACT Medical PROACT are pleased to offer, the new Nonin Lifesense II widescreen colour Capnograph with Oximetry. The new high resolution colour touchscreen and easy adjustable alarms offers, fast reliable and affordable Capnography. Along with the assurance of Nonin’s PureSat Pulse Oximetry in a compact user friendly package. PROACT also offer the PC-900B Handheld Capnography and Oximeter by Creative Medical. This lightweight monitor with an extremely user friendly interface.

The PC-900B supported with Creative’s Variable Flow (50-250ml/min) Sidestream technology allowing it to be used for intubated and nonintubated patients. It can be used to monitor EtC02/FiCO2, RR, SpO2 and PR. It comes with user adjustable audio and visual alarms for all parameters and apnoea. The adjustable pump flow rate allows it to be used with very low flow sample user. Tel: 01536 461981 Email: Web:

UK manufacturer and repairer of surgical instruments

Bespoke surgical instruments designed and manufactured to your specifications. New DUO surface finish combines bead blasting for anti-glare and bright polish for cleaning efficacy. TiN & DLC coatings provide anti-fouling properties and are available in various colours for identification. Bespoke design including specialist instrument ranges in Orthopaedics.

Tel: 01702 602050 Email:


Journal of Perioperative Practice PROCUREMENT GUIDE November 2016 Volume 05 Issue 05

Product News

Professional Laryngoscopes PROACT have been providing innovative Laryngoscope solutions for over 20 years.

With many unique features our full metal disposable Laryngoscopes offer industry leading reliability, strength and no compromise in performance or safety. We offer the disposable Metal Max® Combi™ all in one Test-In-Bag, handle and blade set with pre-loaded batteries, as well as a full range of Green System Fibre Optic and Conventional Metal Max® meLED blades. PROACT offers

a complete solution for reliable of cost effective intubation. PROACT are official distributors for Heine Laryngoscopes offering the Classic+ Fibre Optic Reusable Autoclavable range with Heine Handles. For further information on our products, please contact us. Tel: 01536 461981 Email: Web:

H4 Medical Ltd can provide your hospital department with consumable and equipment solutions

Paediatric Neo-Natal Drape has been custom made for Neo-Natal Theatres.

Stainless Steel Transport Trolleys have been made with a unique internal runner system designed to fit plastic endoscopy trays so they can be transported externally.

Our Stainless Steel Instrument Baskets are available in any size and can be customised with silicone or stainless steel fittings.

The single location racking system UbeFlex ensures no procedure trays are stacked and also aims to reduce the physical handling of wrapped trays. If used correctly the system can reduce the number of torn drapes and improve on manual handling from a health and safety aspect.

Tel: +44 (0)161 743 9772 E-mail: Web:


Journal of Perioperative Practice PROCUREMENT GUIDE November 2016 Volume 05 Issue 05

Product News

PRO-Breathe® Airway Management from PROACT Medical that combine effective clinical performance with superb value.

New to our full range of PROBreathe® Endotracheal tubes are our Suction ET tubes which also offers an evacuation lumen to help prevent VAP. Within the premium range we also offer Endotracheal tube introducers (Bougies) and Intubation Stylets

The PRO-Breathe® range of Laryngeal Airways offering excellent performance and value. Available in all patient sizes with disposable PVC, disposable silicone or autoclavable reusable silicone, all three options offer clear observation of airway patency and come in either standard or an Armourflex® reinforced version. For further information on our products, please contact us. Tel: 01536 461981 Email: Web:

PROTECTIVE APPAREL COMFORT THAT DRIVES COMPLIANCE Medline has a large portfolio of comfortable, affordable protective apparel products that will keep both patients and health care professionals safe during procedures and that optimise infection control processes. The protective apparel range includes a large variety of facemasks, isolation gowns, footwear isol and headwear.

To learn more about Medline and our products, visit

Detergent choice from schülke gigasan® ND from schülke is the latest addition to the extensive range of disinfectants and detergents from schülke, which is designed to offer choice, convenience and cost savings. gigasan ND is a non-enzymatic neutral detergent for the manual cleaning of medical and surgical instruments, including endoscopes and endoscopy equipment. Because of the ultra- concentrated formulation a 5 litre container of gigasan ND can be diluted into 12,500 litres of in-use solution. This makes gigasan ND a highly cost effective neutral detergent and also saves on storage space.

If an enzymatic detergent is preferred, gigazyme® contains enzymes and surfactants for optimum cleaning performance. gigazyme is available in both 2 litre and 5 litre pack sizes. Whether gigasan ND or gigazyme is used, gigazyme® ready-to-use spray foam can be used for the immediate pre-cleaning and disinfection of surgical instruments, including flexible endoscopes.

gigazyme spray foam includes three different enzymes for cleaning and disinfection and is designed to keep soiled instruments moist for a prolonged period of time. Tel: 0114 254 3500 Email: Web: schülke UK Ltd, Cygnet House, 1 Jenkin Road, Meadowhall, Sheffield S9 1AT


Journal of Perioperative Practice PROCUREMENT GUIDE November 2016 Volume 05 Issue 05

Product News

Wardray Premise Wardray Premise Ltd are delighted to be appointed as a distributor of the new IV-eye® vein imager. This innovative product helps healthcare professionals find a suitable vein for peripheral venepuncture or cannulation. It provides a real-time clear image of a patient’s vascular structure, using near infrared light. It’s easy to operate,

requires no calibration and minimal training.

This product’s appeal is not limited to one hospital department; it’s competitively priced; and represents an affordable piece of equipment.

The IV-eye® vein imager helps reduce unsuccessful needle stick attempts, and assists in the best choice of vein, supporting better clinical outcomes and increased patient satisfaction. It’s a portable, lightweight, handheld device, similar in size to a smartphone.

Contact Wardray for more information. Tel: 020 8398 9911 Email:

Are You Protected Against Surgical Smoke? The dangers of surgical smoke: Airway inflammation






“Evidence for exposure and harmful effects of diathermy plumes (surgical smoke)” Published by the Health and Safety Executive 06/12

“...medical staff in the operating theatre are (potentially) increasingly exposed...”

Chronic bronchitis

“...dedicated smoke evacuation/extraction devices are effective at reducing the levels of surgical smoke......”

ClearFlowTM Smoke Evacuation System • Low-cost and quick set-up • Evacuates smoke, particulates and aerosolized pathogens without loss of pneumoperitoneum • Provides a clear view of the surgical field • Absorbs odours and toxic chemicals

Contact LaproSurge for a trial

T: 01923 220 711




Journal of Perioperative Practice PROCUREMENT GUIDE November 2016 Volume 05 Issue 05

Product News

VacSax VacSax, UK leaders in the design and manufacture of disposable suction system for use in all Departments within the hospital, has taken the unprecedented step to manufacture all Suction Liner Products with Antimicrobial Protection.

Founded in 1996, the company currently exports to more than 25 countries around the world. The VacSax BactiClear® Antimicrobial system is seen by over 60% of hospital beds across the UK and has been proven to reduce harmful bacteria such as MRSA and E-Coli by up to 99 per cent as independently tested to the ISO 22196:2011 standard. VacSax BactiClear® Antimicrobial Suction Liner system is the only system where all external surfaces are totally antimicrobial, designed to minimise the risk of cross-infection.

VacSax Bacticlear® Antimicrobial liners are available in 1 litre, 2 litre and 3 litre versions and are PVC-free, producing only carbon dioxide and water upon 100% combustion. The unique patented designed liner is folded for ease of storage and begins to inflate as soon as the vacuum is attached. VacSax Bacticlear® Antimicrobial canisters fit any bracket within the hospital and are suitable for all clinical areas.

3M Patient Warming Solutions 3M SpotOn Temperature Monitoring System TM


The next generation in


Monitoring Temperature is a Vital Sign: Introducing the 3M™ SpotOn™ Temperature Monitoring System From the makers of 3M™ Bair Hugger™ Therapy and the 3M™ Bair Paws™ System comes an accurate, non-invasive and simple way to monitor core temperature throughout the perioperative process. To learn more about the innovative new SpotOn system, please visit or call us on 0845 8734168 to book an appointment. 3M and the 3M logo are trademarks of 3M Company. BAIR HUGGER, BAIR PAWS, SPOTON and the SPOTON graphical element are trademarks of 3M. © 3M 2014. All rights reserved.

UK Ad_08/14 125x180.indd 1

15/08/2014 08:05

“Let’s ensure we are HTM cleaning compliant” Prolystica® Instrument Cleaning Chemistry A choice of cleaning chemistries that cleans and protects endoscopy and surgical instruments in concentrate (2x) or ultra concentrated formulations.

STERIS are here to help you with the new HTM guidelines 6 key products to verify cleaning in your CSSD and Endoscopy departments The new updated HTM guidance documents include a defined protein detection value and the addition of cleaning process challenge device. As a result, you must ensure that your cleaning processes are verified and compliant to the HTM 01-01 and HTM 01-06 guidelines. STERIS & Albert Browne Ltd commit to discuss and support your compliance needs, utilising our world class expertise and globally trusted products to ensure you get what you need, when you need it. There are 6 key product lines that will give you the reassurance required to verify that all your processes are fully compliant. Talk to us today, or if you have any questions, why not

Global leaders in infection prevention, contamination control and critical care technologies

PRE Klenz™ Transport Gel Ready to use free rinsing instrument transport gel to keep your soiled used instruments moist during transport and storage after use.

Browne STF Load Check PCD Standardised, consistent and multi-directional load check indicator for cleaning verification of instrument washer disinfectors.

Browne STF HexaLumen™ Automatic Endoscope Washer PCD An ultra-convenient patented endoscope WD cleaning verification test.

Browne RESI-TEST™ Protein Detection Test A rapid and convenient protein detection test, sensitive down to 1μg protein detection. A NEW easy to use self contained pen format now available.

Sampling Technology For use with the Browne RESI-TEST protein detection kit.

World class sterility assurance products

STERIS Solutions Ltd. 190 Waterside Road, Hamilton Industrial Park, Leicester LE5 1QZ Tel: 0116 2740600 Fax: 0116 2764078

JPP PG November 2016 (Vol:05 Issue:05)