Introduction There are significant risks associated with pleural procedures.¹ NHS England have been cataloguing never events since 2012 and pleural procedure related events are one of the most common procedures causing harm that we as physicians perform.² The WHO Surgical Checklist was developed to minimise morbidity and mortality associated with high-risk procedures.³ We introduced a modified WHO safety checklist for all pleural procedures following 2 never events in our trust.

Aim We wished to establish the use of the modified WHO safety checklist for all pleural procedures throughout the trust, excepting those done in emergency situations.

Methods We completed audits to review the implementation of the checklist. This was following writing trust guidelines, extensive teaching and presentations throughout the trust and to multiple departments on its use over a three-year period. We completed retrospective, spot check audits for one month of all pleural procedures in November 2013 and then re-audit in November 2014.

Results In 2013 the checklist was used in 14/40 of cases (35% overall, 47% of medical patients) and re-audit showed similar results with its use in 20/47 (38%).

Discussion Following Route Cause Analysis of 2 never events, a modified WHO safety checklist was identified as a potential way of preventing future similar adverse events in our trust. Despite numerous teaching sessions and discussion in other fora we have seen that it is still not being used in the majority of cases. We feel that the use of safety checklists should be considered for all procedures that have the potential for serious harm and will continue to strive towards implementing this within our trust. It is possible that if it were to be nationally mandated or included in national guidelines that this would bring further weight towards its use.

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References 1 National Patient Safety Agency. Rapid Response Report: Risks of Chest Drain Insertion. 2008, reference NPSA/2008/RRR003. http://www.nrls.npsa.nhs.uk/resources/?entryid45=59887 (accessed 1 Oct 2015)

2 NHS England. Never Events Summary 2014 http://www.england.nhs.uk/wp-content/uploads/2014/12/2013-14-NE-data-FINAL.pdf (accessed 1 Oct 2015)

3 Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491–9