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The original National Safety Standards for Invasive Procedures (NatSSIPs) were published in 2015. Our understanding of how to deliver safe care in in a complex and pressurised system is evolving. These revised standards (NatSSIPs2) are intended to share the learning and best practice to support multidisciplinary teams and organisations to deliver safer care.

NatSSIPs2 consists of two inter-related sets of standards:

The organisational standards are clear expectations of what Trusts and external bodies should do to support teams to deliver safe invasive care.

The sequential standards are the procedural steps that should be taken where appropriate by individuals and teams, for every patient undergoing an invasive procedure.

The NatSSIPs2 have evolved to have less emphasis on tick boxes or rare 'Never Events' and now include cautions, priorities and a clear concept of proportionate checks based on risk. We recognise that 'teams' change or may be newly formed on the day of a procedure, and therefore require clear processes. NatSSIPs2 should form the basis of improvement work, inspections and curricula.
Key principles in NatSSIPs2 include:

An update of the WHO Five steps to safer surgery of Team Brief, Sign In, Time Out, Sign Out and Handover/Debrief to include three more steps to make the Sequential Standards (Steps): Consent and Procedural verification; Safe use of implants; and Reconciliation of items (to prevent retained foreign objects). 'The NatSSIPs Eight' should be in place for every relevant patient.

That checks performed by an engaged team enable communication and save misunderstandings, reduce risk, provide clarity and set expectations

The central role of the patient as a participant in safety checks.

The NatSSIPs2 have been written by practising clinicians, from across the four UK nations, across disciplines, professions and organisations, with patient and organisational input and published by the Centre for Perioperative Care. They incorporate safety science and learning from all UK nations' patient safety strategies and major reports and investigations.

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The National Safety Standards for Invasive Procedures (NatSSIPs)

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CPOC has been tasked by NHSE/I to review The National Safety Standards for Invasive Procedures standards

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Bloom's taxonomy has long been used by teachers everywhere to help plan lessons and designing curricula but what is it and how can it be used?

What is Bloom's Taxonomy? Bloom's taxonomy (the cognitive domain) is a hierarchical arrangement of 6 processes where each level involves a deeper cognitive understanding. The levels go from simplest to complex: Remember, Understand, Apply, Analyse, Evaluate, Create. They allow students to build on their prior understanding.

I think you'll agree with me when I say, finding a learning theory that most teachers agree on is like hunting for the lost city of Atlantis.

Or is it?

It turns out that it's been staring us in the face all along!

Unless you have been living under a rock or in a dark cave for your entire teaching career, you will have come across Bloom's Taxonomy.

In this definitive guide, I will explain where it came from, what it is exactly and how you can implement it in YOUR classroom!

Who was Benjamin Bloom?

Benjamin Bloom (1913 - 1999), was an American educational psychologist who developed a classification of learning levels (now known as Bloom's Taxonomy) with his colleagues.

Bloom studied at Pennsylvania State University, where he earned his bachelor's and master's degrees.

He received his PhD from the University of Chicago in 1942, where he worked with the highly respected education expert Ralph Tyler and was a talented teacher and was especially interested in students' thought processes while learning.

Benjamin Bloom Biography

Bloom was born on 21st Feb.1913 in Lansford, Pennsylvania. During his early childhood and adolescence, he was extremely interested in the world around him and methods of acquiring knowledge and information.

He loved to read and write research papers and continued to do so throughout his career, using the vast amount of knowledge he gained in his professional work.

He was extremely devoted to his family, wife, and sons. He taught his children various useful skills, often listening to and composing music and playing board games with them.

Bloom's Pedagogical Research

Bloom had an excellent career. In the early years, he was the director of the examining board of the University of Chicago, heading a group of leading school psychologists with whom he worked to advance this scientific discipline.

As part of his work at the university, he founded the MESA (Measurement, Evaluation, Statistical Analysis) program.

The MESA program encourages scientists and analysts to think deeply about the manner and practice of assessment. Also, Bloom was chairman of the Faculty Admissions Committee.

The Birth of the Mastery Model

In his research, Bloom concluded that achieving the highest results in a particular field of work requires at least decades of dedication, renunciation and hard work.

Bloom surveyed a sample of about 120 leading mathematicians, physicists, biochemists, artists, pianists, athletes (tennis players, swimmers etc).

The result of the research showed that each of them needed at least 10-15 years of hard work (learning, practising, coaching) and dedication to achieve mastery in their specific area of ​​expertise.

The role of educators, teachers, and professors during their professional work improves the conditions in the environment of students to express their knowledge, talents of ingenuity in the highest possible sense.

In 1957, he was sent by the Ford Foundation to conduct an evaluation survey in India which led to the revision of their examination and evaluation system.

Bloom was quite rightly recognised as an advisor to education around the world. His work on learning theories is essential study material for any teacher

He also complimented his rich career with activism at the International Association for the Evaluation of Educational Achievements (IEA).

Who was Benjamin Bloom Influenced by?

Bloom believed that learning was a process and that it was the teacher's job to plan lessons and assignments to help students achieve the set goals.

Ralph W. Tyler

Bloom's work on setting goals for educational evaluation and the curriculum was influenced by his mentor Ralph W. Tyler (1902-1994).

Bloom was a researcher under Tyler's mentorship during a distinguished Eight-Year Study (1934 -1942).

The goal of the study was to allow schools to investigate and evaluate alternative methods of assessment in schools.

Tyler worked on the theory and development of the curriculum and the evaluation of the educational process. Promoting behavioral goals, he understood learning as a process of adopting new behaviors.

John B. Carroll

John B. Carrol (1916 - 2003) was an American psychologist and author of "School Learning Model". Bloom was impressed with Carrolls' optimism, especially the idea that differentiates students only in the views they take to learn the material.

Then, with the help of a teacher, each child could achieve a certain, required level of knowledge.

Bloom was also influenced by the work of pioneers in individualised teaching, especially (1922) and his Winnetka Plan and (1926) and his school experiment.

Individualised Learning

The advantage of individual learning and mentoring is that if a student makes a mistake, he/she receives feedback from a mentor, then a correction follows to ensure the performance and high quality of work.

Successful students search the textbook and relevant sources for correcting mistakes so that they do not repeat themselves.

With the help of his mentor, Bloom developed methods that would create a master of science from students, not just those who would memorise theory and facts and repeat the lessons learned.

Elliot W. Eisner

Elliot W. Eisner (1933 - 2014) was Bloom's student in the education department of the University of Chicago.

Bloom helped his students understand through their own experiences.

Most professors would try to explain the theory but Bloom worked through experiments with students. Bloom inspired his students and associates to dedicate themselves and explore educational opportunities.

He was an optimist based on real facts.

According to Eisner, Bloom was in love with the discovery process and developing strategies in a scientific way.

Benjamin Bloom made a significant impact on the scientific work of his students, contemporaries, and associates.

"After forty years of intensive research on school learning in the United States as well as abroad, my major conclusion is: What any person in the world can learn, almost all persons can learn if provided with appropriate prior and current conditions of learning."
"Developing Talent in Young People" by Benjamin Bloom"

Bloom's Domains of Learning

With his colleagues David Krathwohl and Anne Harrow, Bloom proposed three domains of learning; The cognitive domain (knowledge), the affective domain (attitudes) and the psychomotor domain (skills).

The Cognitive Domain (Bloom's Taxonomy)

The first of the domains to be proposed was the cognitive domain (1956), this is the one we commonly refer to as Bloom's taxonomy.

Taxonomy is a scientific discipline that classifies certain organisms based on their similarities and differences.

The cognitive domain suggests that objectives can be ranked in order of their cognitive difficulty.

It is these ranked classifications that teachers across the world are familiar with. The original order ranging from "knowledge" at the most basic to "evaluation" at the most cognitively taxing, is as follows:

Bloom's taxonomy is not a simple classification scheme - it is an effort to arrange different thought processes hierarchically.

Each level depends on the student's ability to complete the previous level or previous levels (phases) For example, a student applying knowledge (Phase 3), he must have certain information (phase 1) and at the same time understand that information (phase 2).

We also see Bloomian cognitive learning rooted in Rosenshine's Principles of instruction.

The Hierarchical Structure of Cognition

nowledge. (Remember previously learned content).

Requirements or instructions that trigger typical knowledge-seeking or identifiable activities. Instructional words you could use include:
List, recite, define, name, match,
quote, recall, tell, label, recognise,
arrange, order, state, relate,
repeat, duplicate.
Example. State: Who is the hero in this story?

nderstanding. (Mastered the meaning of the content).

This level refers to the student's ability to understand what is being said, to be able to present in his or her way the content and to understand the conclusions that follow directly from content, claims or results.
Describe, explain, paraphrase,
summarise, interpret,
identify, classify, report, indicate, formulate, express, translate, review.
Example. Explain in your own words, what is the story about?

Application. (Applies the learned in new and concrete situations).

This is about the ability to use some abstractions in specific situations, that is, to solve problems using learned concepts, ideas, rules, or procedures.

Related activities are initiated by the following instructions in the students:
Predict, expand, compare, classify, calculate, apply, solve, illustrate, use, demonstrate, determine, model, operate,
choose, select, perform.
Example: Using what you have learnt about group one metals, predict what will happen when you put a chunk of Lithium in the water.

nalysis. (Breaks down the content and structure of the material).

This level of educational goals is based on logical thinking. To achieve the objectives appropriate to the level of analysis, students should be instructed such as:
Distinguish, confirm, sketch, list all possible consequences, categorise, organise, translate, contrast, differentiate, question, investigate, examine, determine, compare, discriminate, detect, calculate, classify, outline, analyse.
Example: Based on your experiment, what chemical reaction leads to ...?

ynthesis. (Formulates and builds new structures from existing knowledge and skills).

This level of goal implies the ability to combine known elements and create a new whole, model, or structure that did not exist before.

The core of achieving this category of goals lies in creative thinking. Students will perform appropriate activities aimed at achieving the goals from this level based on the following instructions:
Create, invent, elaborate, summarise, make, picture, imagine, modify, connect, define assumptions, predict, determine keywords (basic thesis, title) combine, minimise, assemble, plan, generalise, manage, write, conclude, prepare, design,
formulate, build, compose, generate, derive.
Example: What would the world look like if humans suddenly vanished?

valuation. (Judges the value of the content for a given purpose).

The objectives at the evaluation level are standards that can be set by the learner, it is their own personal interpretation. Evaluative goals can be initiated by the instructions:
Evaluate, prove, refute, argue, justify, support, convince, debate, resolve the ambiguity, weigh, prioritise, judge.
Example: Justify your opinion on climate change?

Bloom's Taxonomy Revised

Bloom's taxonomy was revised by Lorin Anderson, a former Bloom student, and David Krathwohl, Bloom's original research partner.

Anderson and Krathwohl (2001) redefined the neuro-cognitive processes in the taxonomy and further arranged them hierarchically by listing the corresponding sublevels.

The revised taxonomy retains six levels of educational goals, but now these are formulated as actions (verbs, not nouns as in Bloom's taxonomy), thus making them easier for teachers to use.

The last two levels have reversed places, so the order is now as follows:

Bloom's Taxonomy provides a framework for teachers, helping them write and plan the goals and objectives of their lessons.

Its main benefit is that it allows teachers to more clearly differentiate their lesson's goals.

Another change was to introduce another dimension that more consistently defines the subcategories within each major level.

In this second dimension, different types of knowledge are represented:

Knowledge of facts and data. (Knowledge of terminology and knowledge of specific details and elements of some content).

Conceptual knowledge. (Knowledge of classifications and categories, knowledge of principles and generalisations and knowledge of theories, models and structures).

rocedural knowledge. (Knowledge of subject-specific skills and knowledge of algorithms, knowledge of subject-specific techniques and methods, and knowledge of the criteria for applying appropriate procedures).

etacognitive knowledge. (Knowledge of strategies, knowledge of what it takes to work on tasks, knowledge of oneself).

Bloom's publication Taxonomy of Educational Objectives has become widely used around the world to assist in the preparation of evaluation materials.

Many teachers make extensive use of Bloom's taxonomy, thanks to the structure it provides in areas such as level assessment knowledge.

Due to its comprehensiveness as a learning theory, Bloom's taxonomy is applicable in different educational situations, at all levels and areas of learning, and is therefore recommended as an indispensable tool in the practice of every teacher.

The Affective Domain

Affective domain - attitudes, values, and interests.

Krathwohl and Bloom proposed the affective domain in 1964 (8 years after the cognitive domain). Like the cognitive domain, it too divides its objectives into hierarchical subdivisions.

This domain addresses the issues of the emotional component of learning and ranges from a basic willingness to receive information to the integration of beliefs, ideas, and attitudes.

The ranked domain subcategories range from "receiving" at the lower end up to "characterisation" at the top. The full ranked list is as follows:

1. Receiving. Being aware of an external stimulus (feel, sense, experience).

2. Responding. Responding to the external stimulus (satisfaction, enjoyment, contribute)

3. Valuing. Referring to the student's belief or appropriation of worth (showing preference or respect).

4. Organisation. The conceptualising and organising of values (examine, clarify, integrate.)

5. Characterisation. The ability to practice and act on their values. (Review, conclude, judge).

As with the cognitive domain, it is assumed that learning at lower levels is a prerequisite for reaching the next, higher level.

To explain the way we approach things from an emotional point of view, Bloom and his colleagues have developed five basic categories:

Receiving refers to the willingness to receive information. For example, an individual accepts the obligation to be in class, listens to others with respect, shows an interest in social issues.

Responding refers to the active participation of an individual in their education.

For example, an individual shows interest in the subject is willing to prepare a presentation, participate in class discussions and likes to help others.

Valuation ranges from simply accepting some value in the lesson to commitment.

For example, an individual expresses faith in democratic processes, respects the role of science in everyday life, shows concern for the well-being of others or shows an understanding of personal and cultural differences.

rganisation refers to the process a person goes through when he or she associates different values, resolves conflicts between them, and begins to adopt them. They adjust behavior to a value system.

For example, they start to recognise the need for a balance between freedom and responsibility in a democracy, accept responsibility for one's behavior, accept standards of professional ethics or adapts behavior to their new value system.

Characterisation is the level of adoption, an individual has a developed system of evaluation in terms of their own beliefs, ideas, and attitudes that guide their behavior consistently and predictably.

For example, They will express confidence in working independently, demonstrate a commitment to the ethics, demonstrate good personal, social and emotional adjustment and lives out healthy life habits.

The Psychomotor Domain

Psychomotor domain - skills.

The psychomotor domain refers to human movement from a psychological perspective, those objectives that are specific to reflex actions, interpretive movements and discreet physical functions.

It is a misunderstanding of the psychomotor domain that physical objectives that support cognitive learning fit the psycho-motor label, e.g.; learning how to chop vegetables or sanding a piece of wood.

These physical actions are a vector for cognitive learning, not psycho-motor learning.

The psychomotor domain is concerned with how we recognise the world around us using our bodies and senses.

For example how we such as learning how to serve in tennis or perform multiple somersaults in high diving or trampolining.

This third domain has received the least attention than the previous two. Bloom and his colleagues did not complete their work on the psychomotor domain leading to later research by other authors.

R.H. Dave (1970)

Dave's psychomotor domain is perhaps the most common version and can be the simplest to apply as a learning theory.

It deals with levels of competency in a physical task. Dave suggested five levels from the initial discovery to mastery of the physical skill.

Imitate

You can observe and copy someone else performing a task.

Manipulate

You can perform a task from memory or follow written or audible instructions.

Precision

You can perform a task without help from others, to a high level of accuracy.

Articulation

You can adapt the processes to fit individual requirements. You can adapt the movement when faced with a complication.

Naturalisation

You can perform movements in an unconscious way. It has become second-nature, we sometimes refer to this as "muscle memory".

Elizabeth Simpson (1972)

Simpson's psychomotor domain is concerned with using and coordinating motor skills. it is a track towards mastery.

Perception

You can use sensory cues to direct you (observation, written or verbal instruction).

Set

You are ready to act. It is a mindset, you are primed to act.

Guided Response

The initial stages of mastering a comples skill, you imitate and use trial and error.

Mechanism

Basic proficiency. You are begining to form habits and have a basic to medium level of mastery.

Complex Overt Response

You can expertly perform complex actions with minimum wasted effort or mistakes.

Adaptation

You can modify your physical movements to overcome new demands.

Origination

You can create new movements, based on your learned movements.

Anita Harrow (1972)

Anita Harrow published her paper in 1972; "A Taxonomy of the Psychomotor Domain". In it, she classified different types of learning in the psycho-motor domain ranging from reflex actions to those require precise control.

Reflex Movements

Movements present from birth or appear naturally through puberty. e.g. Breathing or contractions associated with menstruation.

Fundamental Movements

Basic movements. Walking, running, jumping etc.

Perceptual Abilities

Movements that require a sensory judgement, for example catching a frisbee or jumping over a hurdle.

Physical Abilities

Movements that require strength, endurance or flexibility.

Skilled Movements

Movements that are learned for a specific purpose. Playing chords on a guitar or sommersaults in gymnastics.

Nondiscursive Communication

Refering to movements associated with non-verbal communication. For example, posture or facial expressions.

How Is Bloom's Taxonomy Used in the Classroom?

Bloom's taxonomy has been developed precisely to help teachers formulate learning outcomes and as a guide to devising assessment criteria tailored to the type of cognitive domains and mental and companion skills being assessed.

The research done by Bloom and his colleagues has multiple implications for teaching practice and the quality of education.

It allows teachers to adequately plan their teaching while respecting the individual abilities of students, as well as using different learning and education strategies, innovating practice and adequately assessing students' knowledge and skills.

Based on the insights gained from such monitoring, teachers can make meaningful adjustments to their curriculum to devote more attention and time to those goals that they did not recognise through their students' learning journey.

If teachers involve the students themselves in this process, encouraging them to self-assess by comparing expected and achieved outcomes, it will also contribute to the development of learning motivation.

Student self-assessment is a brilliant tool for developing students' responsibility for their progress and success in learning.

After reviewing the work of Bloom and his associates, it is evident that his contribution to the planning, organisation and structuring of the educational process is remarkable.

Bloom's Taxonomy FAQ

What Is the Cognitive Domain?

What Is the Affective Domain?

What Is the Psychomotor Domain?

Similar Posts:

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The Definitive Guide to Bloom's Taxonomy - Education Corner

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Bloom's taxonomy has long been used by teachers everywhere to help plan lessons and designing curricula but what is it and how can it be used? What is Bloom's Taxonomy? Bloom's taxonomy (the cognitive domain) is a hierarchical arrangement of 6 processes where each level involves a deeper cognitive understanding.

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Children's Surgery Guidelines | British Association of Paediatric Surgeons

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Children's Surgery Guidelines | British Association of Paediatric Surgeons

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British Association of Paediatric Surgeons

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Children's Surgery Guidelines | British Association of Paediatric Surgeons

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This guideline covers care for adults (aged 18 and over) having elective or emergency surgery, including dental surgery. It covers all phases of perioperative care, from the time people are booked for surgery until they are discharged afterward. The guideline includes recommendations on preparing for surgery, keeping people safe during surgery and pain relief during recovery.

The recommendations in this guideline were developed before the COVID-19 pandemic.

Recommendations

This guideline includes recommendations on:

Who is it for?

Healthcare professionals, including dentists, in primary, secondary and tertiary care

Commissioners, planners and service providers, including those in non-NHS organisations commissioned to provide services for the NHS or local authorities

Adults having elective or emergency surgery, their families and carers

Guideline development process
How we develop NICE guidelines
This guideline updates and replaces NICE medical technologies guidance 3 (published March 2011).

Your responsibility

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.

All problems (adverse events) related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme.

Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

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This guideline covers care for adults (aged 18 and over) having elective or emergency surgery, including dental surgery. It covers all phases of perioperative

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Template SOP for 'Prep, stop, block' https://t.co/uZDAkCWpU4 #Anaesthesia2022

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More SBYB resources: https://t.co/SQmV4BunjN #Anaesthesia2022 pic.twitter.com/3CcuwaiPQl
— JP Lomas (@jplomas) May 17, 2022

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Template SOP for 'Prep, stop, block' https://t.co/uZDAkCWpU4 #Anaesthesia2022

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Template SOP for 'Prep, stop, block' https://t.co/uZDAkCWpU4 #Anaesthesia2022

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Full SOP (includes FAQs)

Stop Before You Block - Training Video 2021

Stop Before You Block - Silent Training Video 2021

Poster Background
In 2018 the newly created Healthcare Safety Investigation Branch (HSIB) investigated the causes of wrong side regional anaesthetic block and invited the Safe Anaesthesia Liaison Group (SALG) to formulate a standard, national policy [1]. A specific ask was to review the status of 'Stop Before You Block' (SBYB) to assess if any improvements could be made.

The resulting working party had representation from RA-UK, the Faculty of Pain Medicine, the RCoA Simulation Working Group and NHS Improvement.

Evidence was gathered via a survey of RA-UK members, formal 3-month trials of the new process across a number of UK sites (both self-reported and observational) and data from a series of 20,000 blocks at South Tyneside and Sunderland NHS Foundation Trust.

The deconstruction of the SBYB process into three explicit steps: Preparation, a Stop moment followed immediately by performance of the Block ( Prep, Stop, Block) is the result of discussions begun in the SALG working party and finalised by the SOP's authors.

Further background to the project and the methods employed is included in this editorial published in Anaesthesia.
What was the problem with the original SBYB process?
Devised by the Nottingham group in 2010, the original SBYB campaign seemed a successful innovation [2]. With a catchy title, it became widely established across the UK and internationally (endorsed by Australian and New Zealand colleges (ANZCA) and widely adopted in the US). Unfortunately, the incidence of wrong side blocks (WSB) remained doggedly at around 1 in 6250 over the years [3].

One problem was that while the original poster stated that the STOP moment should take place immediately before needle insertion and that the site should be reconciled with the surgical site mark, later research indicated that this was widely misinterpreted. The recommendation that both anaesthetist and assistant should check together was overlooked, and the 'stop' moment was too often performed at the WHO 'sign in' to the anaesthetic room which was up to 30-45 minutes before block placement.

The original guidance encouraged local variation in how SBYB was interpreted. Thus, some Trusts came to use warning stickers (which may become displaced); some to mark the limb to be blocked, others as a warning not to block that side [4,5]. These local variations can be particularly confusing for rotating clinicians (trainees and locums), and also make difficult mapping an adverse event against a consistent framework [6].
How does the new approach differ?
The new approach is presented as a 'standard operating policy' (SOP) to be applied nationally. While the SBYB 'brand' is retained, the process of performing a block is deconstructed into three discrete steps: Prep, Stop, Block. Any future wrong-side peripheral nerve blocks (WSBs) can be investigated and mapped against a common framework.

The WHO 'Sign In' is performed on arrival of the patient in the anaesthesia room. General anaesthesia may or may not be administered first (or not at all). Regardless, the Blocker (the person who performs the block, who may commonly be an anaesthetist) prepares the local anaesthetic solution and places the labelled syringe with a suitable nerve block needle in a dedicated tray/container, which is handed over to the Assistant, out of the Blocker's immediate reach. The Blocker and Assistant should position the patient and equipment in the final position ready for the block and may perform a preliminary 'pre-scan' with ultrasound. The Blocker dons gloves and prepares the site (cleaning, draping) for the block. Where drapes cover the surgical site mark, the Assistant should ensure they can later reveal the mark for the Stop moment. Ideally, the surgical site mark should always be visible.
Step 2: Stop moment
The stop moment is a two-person step that happens only after preparation is complete and thus immediately before needle insertion. When ready, the Blocker formally announces that they have completed all preparation and is ready to block using a consistent form of words: " I've completed my prep; let's Stop Before You Block". The Assistant similarly should reply: "OK, let's Stop Before You Block". The Blocker and Blocker's Assistant together should then check the block side by viewing the surgical site mark and verbally confirming the correct side; the Assistant reconciles this with the consent form. If the patient is awake and unsedated, they may also confirm the side is correct.
Step 3: Block
Only when the correct side is confirmed does the Assistant hand the tray/container to the Blocker. The Blocker immediately performs the block. Any delay between handing back the tray and/or performing the block should require the Blocker and Assistant to re-start the SBYB process at Step 1. This re-start is to re-create a situation in which the block immediately follows the handing of tray from Assistant to Blocker. Re-start might be at the very start of the Preparation stage (e.g., if the site has become contaminated or later; but will always involve first handing the tray back to the Assistant.
Dr Nat Haslam Dr Nigel Bedforth
References Consultant Anaesthetist, Nottingham University NHS Trust & Hon Associate Professor, University of Nottingham
[email protected]
Consultant Anaesthetist, South Tyneside and Sunderland NHS Foundation Trust. Honorary Secretary RA-UK
[email protected]
Professor Jaideep J Pandit
University of Oxford
[email protected]

Healthcare Safety Investigation Branch: Administering a wrong site nerve block. https://www.hsib.org.uk/investigations-cases/administering-wrong-site-nerve-block/ (accessed 2/11/2021)

RA-UK website: Stop Before You Block https://www.ra-uk.org/index.php/stop-before-you-block (accessed 2/11/2021)

Pandit JJ, Matthews, J, Pandit M. Editorial: ''Mock before you block'': an in-built action-check to prevent wrong-side anaesthetic nerve blocks. Anaesthesia 2017; 72: 150-155.

Chikkabbaiah V, French J, Townsley P, Bedforth N. Further reducing the risk of wrong site block. Anaesthesia 2015; 70: 1453.

Pollard R, Sivasubramaniam S. Stop before you block stickers. Anaesthesia 2017; 72: 1156-7.

Hopping, M., Merry, A,F,. & Pandit, J,J. Exploring performance of, and attitudes to, Stop- and Mock-Before-You-Block in preventing wrong-side blocks. Anaesthesia 2018; 73: 421-7.

Please note that the information on this page is the same as that on the RA-UK website with permission.

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Full SOP (includes FAQs) Stop Before You Block - Training Video 2021 Stop Before You Block - Silent Training Video 2021 Poster Background In 2018 the newly created Healthcare Safety Investigation Branch (HSIB) investigated the causes of wrong side regional anaesthetic block and invited the Safe Anaesthesia Liaison Group (SALG) to formulate a standard, national policy [1].

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Thanks Simon. A big part of scaling up Critical Care will be making good quality information easily accessible for those with enough ICM knowledge to make a big difference but understandable anxieties about stepping up. Another #TeamBolton example:  https://t.co/K1s62NcROu https://t.co/7yhZRWgJuk https://t.co/x895pEhk3t

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Thanks Simon. A big part of scaling up Critical Care will be making good quality information easily accessible for those with enough ICM knowledge to make a big difference but understandable anxieties about stepping up. Another #TeamBolton example:  https://t.co/K1s62NcROu https://t.co/7yhZRWgJuk https://t.co/x895pEhk3t

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Lots of Qs at work about this!
Covid 19: A primer on ICU care for the non-intensivist. For those who may be redeployed to support critical care services during the pandemic
@jplomas @traumagasdoc @andyneill
@stemlyns #FOAMed… https://t.co/Kkb9cV2g7b https://t.co/1vEnOZswnV

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Thanks Simon. A big part of scaling up Critical Care will be making good quality information easily accessible for those with enough ICM knowledge to make a big difference but understandable anxieties about stepping up. Another #TeamBolton example: https://t.co/K1s62NcROu https://t.co/x895pEhk3t pic.twitter.com/7yhZRWgJuk
— JP Lomas (@jplomas) March 24, 2020

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Thanks Simon. A big part of scaling up Critical Care will be making good quality information easily accessible for those with enough ICM knowledge to make a big difference but understandable anxieties about stepping up. Another #TeamBolton example:  https://t.co/K1s62NcROu https://t.co/7yhZRWgJuk https://t.co/x895pEhk3t

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Lots of Qs at work about this!
Covid 19: A primer on ICU care for the non-intensivist. For those who may be redeployed to support critical care services during the pandemic
@jplomas @traumagasdoc @andyneill
@stemlyns #FOAMed… https://t.co/Kkb9cV2g7b https://t.co/1vEnOZswnV

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Thanks Simon. A big part of scaling up Critical Care will be making good quality information easily accessible for those with enough ICM knowledge to make a big difference but understandable anxieties about stepping up. Another #TeamBolton example:  https://t.co/K1s62NcROu https://t.co/7yhZRWgJuk https://t.co/x895pEhk3t

# data[].attributes.attachment_link.metadata.attachment_props.text
Thanks Simon. A big part of scaling up Critical Care will be making good quality information easily accessible for those with enough ICM knowledge to make a big difference but understandable anxieties about stepping up. Another #TeamBolton example:  https://t.co/K1s62NcROu https://t.co/7yhZRWgJuk https://t.co/x895pEhk3t

# data[].attributes.attachment_link.metadata.attachment_props.referenced_tweets[].text
Lots of Qs at work about this!
Covid 19: A primer on ICU care for the non-intensivist. For those who may be redeployed to support critical care services during the pandemic
@jplomas @traumagasdoc @andyneill
@stemlyns #FOAMed… https://t.co/Kkb9cV2g7b https://t.co/1vEnOZswnV

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Guidelines for recovery of elective surgery in children's services

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Guidelines for recovery of elective surgery in children's services

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The Royal College of Peadiatrics and Child Health (RCPCH) has published national guidance for the recovery of elective surgery in children.

The aim of the guidance is to provide guidance on evidence-based practice that will enable recovery of children's elective surgery.

The guidance has been developed by the following organisations: NHS England, Public Health England, the Royal College of Surgeons of England, Royal College of Anaesthesia, Royal College of Paediatrics and Child Health, the Children's Surgical Forum, British Association of Paediatric Surgeons, Association of Paediatric Anaesthetists of Great Britain and Ireland, and The Association for Perioperative Practice.

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RCPCH publishes national guidance for the recovery of elective surgery in children

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The Royal College of Peadiatrics and Child Health (RCPCH) has published national guidance for the recovery of elective surgery in children. The aim of the guidance is to provide guidance on evidence-based practice that will enable recovery of children's elective surgery.

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Day Surgery for Children and Young People

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Day Surgery for Children and Young People

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Day Surgery for Children and Young People

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Paediatric Perioperative Care (PPOC) | APAGBI

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Paediatric Perioperative Care (PPOC) | APAGBI

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The P-POC group was started in 2015 by a group of paediatric anaesthetists who recognised the importance of pre-assessment for children and perioperative medicine aimed at improving outcomes from surgery and anaesthesia.

There is a limited presence of standards in existing publications around perioperative medicine and preassessment in children. GPAS (RCOA, 2017) has one specific reference to this and also highlights perioperative medicine as one of the important areas of future research. There is very little published on perioperative care which could support the development of services in hospitals.

There is a lack of evidence to help advance perioperative medicine for children. There is a need to demonstrate benefit in a measurable form, beyond just cost savings and improved theatre list efficiency. The P-POC group hope to start projects looking at the broader aspects of paediatric perioperative care and also concentrate on some specific care pathways.

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The P-POC group was started in 2015 by a group of paediatric anaesthetists who recognised the importance of pre-assessment for children and perioperative medicine aimed at improving outcomes from surgery and anaesthesia. There is a limited presence of standards in existing publications around perioperative medicine and preassessment in children.

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Surgical First Assistant — Royal College of Surgeons

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Surgical First Assistant — Royal College of Surgeons

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The Royal College of Surgeons events programme includes a range of members' events in London and across the UK, educational events and special events showcasing the College's museum, library and archive collections.

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Roles and responsibilities of the surgical care team - Royal College of Surgeons

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The Royal College of Surgeons events programme includes a range of members' events in London and across the UK, educational events and special events showcasing the College's museum, library and archive collections.

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Children and young people ethics toolkit

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Children and young people ethics toolkit

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The British Medical Association is the trade union and professional body for doctors in the UK.

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What you'll get from this guide

The key legal and ethical factors doctors need to consider when making decisions about children and young people.

More detailed guidance on some of the more sensitive issues that can arise - for example, disputes, child safeguarding concerns, and access to sexual health services.

Signposts to other key resources - for example, guidance from the General Medical Council (GMC).

How to use this guide

This guidance will provide you with the key legal and ethical considerations you need to take into account when making a decision about children and young people (under 18 years in England, Wales and Northern Ireland; under 16 years in Scotland).

It is not a set of rules or instructions, or a substitute for careful reflection and discussion with colleagues.

You can seek additional advice on specific dilemmas from the BMA's medical ethics and human rights department, the GMC, or your medical defence organisation.

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Children and young people ethics toolkit

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What you'll get from this guide The key legal and ethical factors doctors need to consider when making decisions about children and young people. More detailed guidance on some of the more sensitive issues that can arise - for example, disputes, child safeguarding concerns, and access to sexual health services.

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Patient consent for peripheral nerve blocks

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Patient consent for peripheral nerve blocks

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Membership of Working Party

Dr Anand Sardesai Consultant Anaesthetist, Cambridge, UK

Dr James French Consultant Anaesthetist, Nottingham, UK

Dr Amit Pawa Consultant Anaesthetist, London, UK

Download as a PDF
Section 1 Introduction Section 2 Information and the process of consent: Section 3 Documenting the consent
Peripheral nerve blocks are routinely performed by anaesthetists to provide anaesthesia and analgesia for patients undergoing limb surgery. Like all procedures in anaesthesia, nerve blocks are associated with certain inherent risks and complications. A properly taken consent can help patients make an informed decision about undergoing nerve blocks and will also protect an anaesthetist from subsequent criticism and litigation.

In 2006, The Association of Anaesthetists of Great Britain and Ireland (AAGBI) published "Consent for Anaesthesia" ¹. According to this document, information about anaesthesia should be provided to patients undergoing elective surgery before they meet their anaesthetist. This is preferably in the form of a patient friendly leaflet (patient information leaflet). Consent should be obtained prior to a patient coming to the anaesthetic room, except under exceptional circumstances. The amount and the nature of information provided to the patient should be aimed at helping the patient to make an informed decision about choosing one of the available options. Patients should also be given an opportunity to ask questions. The discussion between patient and anaesthetist should be documented in the notes; this documentation should cover what risks, benefits and alternatives were explained to the patient.

RAUK (Regional Anaesthesia United Kingdom) advise that all the recommendations made in the AAGBI guideline apply to patients having a nerve block. This RAUK guideline contains additional advice that is specific to Regional Anaesthesia.

Section 2: Information and the process of consent for nerve block

2.1. Information about nerve blocks can be provided preoperatively by an anaesthetist and/or other health care professionals, including surgeons and pre-assessment nurses. However, ultimate responsibility for ensuring the adequacy of information provided to the patient lies with the person performing the block.

2.2. Timing of consent

2.2.1 For elective surgery, information should ideally be given prior to the day of surgery. This could be in the form of a 'Patient information leaflet'. This can be given to the patient by the surgeon at the time of booking or by a nurse in the pre-assessment clinic. However this may not be always possible. Information about the nerve block can be given on the day of surgery, provided adequate time has been given for the patient to understand the information and to ask questions. Consent for peripheral nerve blocks should not be obtained in the anaesthetic room.

2.2.2. For emergency surgery it will not always be possible to provide a patient information leaflet prior to surgery. The consent should be obtained prior to the patient coming to the anaesthetic room. Under exceptional circumstances it may be necessary to obtain consent in the anaesthetic room.

2.3. Obtaining consent

2.3.1. Although information for nerve block can be provided by other health care professionals, consent should ideally be obtained by the person performing the block.

2.3.2. Consent for the procedure may be obtained by a person who is not performing the block, provided that he/she understands the processes, the risks involved, possible complications, the benefits of the block to the patient and any alternatives (e.g. patient controlled analgesia). However, the person performing the block is still responsible for ensuring that adequate consent has been obtained and specifically, that the patient has consented for him/her to perform the block.

2.3.3. If a trainee is working under the direct supervision of a Consultant, then it is the responsibility of that consultant to ensure adequate consent has been obtained for the trainee to perform the block, and that risks are minimised.

If a trainee is not working under the direct supervision of a Consultant, then it is the responsibility of trainee to ensure adequate consent has been obtained and that the indirectly supervising consultant has been informed, if appropriate. Trainees can function autonomously within their level of expertise, as defined by the General Medical Council ². If discussion has occurred with the supervising consultant, this should be recorded and the consultant identified by name.

2.4. Patient information Leaflets

2.4.1. Patient information leaflets are a useful source of information. However they may not help the patient remember all the details of the nerve block ³. They are not a substitute for talking to the patient directly about the nerve block.

2.4.2. Patient information leaflets should be available in the language understood by the patient. If this is not possible, a translator should be provided.

2.4.3. Patient information leaflets can be given to the patient by any healthcare professional, but the anaesthetist performing the block should make sure that the patient has read and understood the contents.

2.4.4. Whenever possible, nationally approved patient information leaflets should be used. They may be modified to reflect local circumstances.

2.4.5. Preoperative multimedia information has been shown to reduce the anxiety of patients undergoing surgery under regional anaesthesia and improve patient experience ⁴. If possible, the patient should be shown a professionally approved video which explains the block procedure. The patient should be given the opportunity to ask any questions relating to the video.

2.4.6. Patient information leaflets should provide a prompt to the patient to ask questions or express any concerns. Contact details and "frequently asked questions" and answers should be provided.

2.4.7. Regular audit and updating of the information provided to the patient should be carried out. The audit may include the quality of information provided and usefulness of the information provided to the patient.

2.5. Content of the consent process

2.5.1. Patients need to know what they are consenting for. They should be told about the benefits (e.g. opioid sparing, early mobilisation, less risk of nausea and vomiting) to them of undergoing nerve block. They also need to be told the alternative options to a nerve block (e.g. having a general anaesthetic for surgery or using patient controlled analgesia for pain relief).

2.5.2. The Patient should be told about the process of nerve blockade, i.e., what he/she will feel and see. This includes use of a nerve stimulator (muscle twitches) and/or ultrasound. If they are going to be sedated for the block then they should be told about this.

Patients should be offered additional sedation or general anaesthesia, together with a clear explanation of the risks and benefits.

2.5.3. The risk of failure and alternative plans for anaesthesia and analgesia should be explained to the patient.

2.5.4. Patients should be told about any risk associated with the nerve block or any immediate side effect (e.g. Horner's syndrome with interscalene block) which has an incidence of >1:100

2.5.5. Any risk that can have either short term (pneumothorax following supraclavicular block) or long term serious consequences (permanent nerve damage) should be discussed.

2.5.6. The exact incidence of nerve damage is not known ⁵⁻⁸. The risk of complications is influenced by numerous factors, including patient co-morbidity, the experience of the anaesthetist, the method of nerve location and the block selected. It should be made clear to the patient that the exact incidence of nerve damage is not known. In the absence of clear figures we can rely only on the incidences quoted in the scientific literature and summarised in leaflets published by the Royal College of Anaesthetists ⁹, which quote an incidence of approximately 1:10 for temporary nerve damage and a range from 1:2000 to 1:5000 for permanent nerve damage.

2.5.7 If a unit or an anaesthetist has audit data which indicates their local incidence of complications, they may quote these figures. However, care should be taken in interpretation, application and explanation of uncontrolled audit data, noting that statistical significance can only be achieved with a considerable sample size when assessing rare occurrences.

2.5.8. For all blocks, patients should be made aware of the risk of thermal damage to the insensate blocked limb. They should also be told that they should avoid driving, using any machinery or cooking while their limb is insensate.

2.5.9. For lower limb blocks the patient should be made aware of the specific risk of falling and heel pressure sores.

2.5.10. There are certain risks which are block specific (e.g. Horner's syndrome following Interscalene block, risk of pneumothorax following periclavicular blockade). These should be discussed with the patient.

2.5.11. If surgery is performed under block alone, then patients should be made aware that they may have tourniquet pain or operative discomfort even with a fully functioning block. They should also be informed that they may feel surgical pain, but that if this happens, the anaesthetist or surgeon will immediately administer alternative effective analgesia.

2.5.12. Patients should be repeatedly told to take postoperative pain relief well in advance of block resolution.

3.1. It is not necessary to obtain specific written consent for RA to facilitate a surgical procedure, as long as written, signed consent has been obtained for the surgery. However, when RA is proposed as the sole therapeutic procedure (e.g. rib fractures, chronic pain therapy), specific signed consent should be obtained, using the local formal consent process.

3.2. All the risks/benefits/alternatives to nerve block that have been discussed with the patient should be documented in the patient's notes. If the patient asks any questions related to nerve blockade, then this discussion should also be documented.

3.3. If the patient has received a patient information leaflet, this should be documented, as well as any discussion relating to it.

3.4 If the patient has a high risk of a complication (e.g., nerve damage in diabetics), or is at higher risk than usual from the effects of the complication (e.g., their occupation), care should be taken to specifically address these issues and record the discussion in the notes.

3.5. It should be made clear in the notes that

The Patient understood all the information given

The patient was given the opportunity to ask questions and all their questions were answered.

http://www.aagbi.org/sites/default/files/consent06.pdf

Consent for anaesthesia. AAGBI publication 2006

http://www.gmc-uk.org/The_Trainee_Doctor_1114.pdf_56439508.pdf

General Medical council guidance for the trainee doctor

1. Turner P. and Williams C. (2002) Informed consent: patients listen and read, but what information do they retain? The New Zealand Medical Journal Vol 115 No.1164

2. Jlala HA, French JL, Foxall GL, Hardman JG, Bedforth NM. Effect of preoperative multimedia information on perioperative anxiety in patients undergoing procedures under regional anaesthesia. Br J Anaesth. 2010;104:369-374

3. Liguori GA. Complications of regional anesthesia: nerve injury and peripheral neural blockade. J Neurosurg Anesthesiol 2004;16:84-6.

4. Auroy Y, Benhamou D, Bargues L, et al. Major complications of regional anesthesia in France: the SOS Regional Anesthesia Hotline Service. Anesthesiology 2002;97:1274-80.

5. Liu SS, Zayas VM, Gordon MA, et al. A prospective, randomized, controlled trial comparing ultrasound versus nerve stimulator guidance for interscalene block for ambulatory should surgery for postoperative neurological symptoms. Anesth Analg 2009;109:265-71.

6. Fredrickson MJ, Kilfoyle DH. Neurological complication analysis of 1000 ultrasound guided peripheral nerve blocks for elective orthopaedic surgery: a prospective study. Anaesthesia 2009;64:836-44.

7. http://www.rcoa.ac.uk/system/files/PI-RISK12-NERVEBLOCK-2013.pdf

Royal College of Anaesthetist document on risk associated with anaesthetic, section 12.

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Patient consent for peripheral nerve blocks

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Dr Anand Sardesai Consultant Anaesthetist, Cambridge, UK Dr James French Consultant Anaesthetist, Nottingham, UK Dr Amit Pawa Consultant Anaesthetist, London, UK Download as a PDF Section 1 Introduction Section 2 Information and the process of consent: Section 3 Documenting the consent Peripheral nerve blocks are routinely performed by anaesthetists to provide anaesthesia and analgesia for patients undergoing limb surgery.

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Consent must be given freely without pressure or undue influence. Pressure may come from other family members, partners or other carers and doctors must be aware of this. Competent adults may refuse a treatment in its entirety, though may not compel a doctor to perform part of a treatment if by refu…

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SALG and RA-UK publish national 'Prep, Stop, Block' protocol

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Safe Anaesthesia Liaison Group (SALG) and Regional Anaesthesia UK (RA-UK) have published a new national Standardised Operating Procedure (SOP) to prevent wrong side block.

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Highlights

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Adequate exposure for robotic surgery requires extreme positioning with safety concerns.

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Patient positioning assumes unique importance for robotic surgery as the position cannot be changed after docking.

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Restricted patient access, operation room space restriction and protecting patient from clashing robotic arms are concerns.

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Positioning related nerve palsies, pressure ulcers, port site necrosis, herniation, and venous thrombosis are preventable.

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Tailor made operation theatre configurations for specific robotic oncosurgeries are presented.

Abstract

Robotic surgery has revolutionised patient management and opened newer doors for the anaesthesiologists regarding patient safety. Patient positioning and operation theatre (OT) configuration assumes unique importance for robotic surgery due to multiple factors. First and fore-most, the position cannot be changed once the robot is docked. Further, adequate surgical exposure requires extreme positioning and revamping of the existing positioning devices. In addition, there is restricted access to the patient and its antecedent problems. Last, but not the least, space restriction and protection of patient from the clashing robotic arms requires special devices and several unfavourable position modifications. Position related nerve palsies, pressure ulcers, port site necrosis, venous thrombosis and other injuries are on the rise in the recent years and appropriate measures may make it largely preventable. This article highlights the major positioning associated deficiencies and problems during robotic surgeries. It also attempts to find practical solutions for the same, and to define the best practices for robotic positioning using a thorough review of literature based on Medline, Embase, and Scopus databases search.

View full text

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Robotic surgery and patient positioning: Ergonomics, clinical pearls and review of literature

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Adequate exposure for robotic surgery requires extreme positioning with safety concerns. * Patient positioning assumes unique importance for robotic surgery as the position cannot be changed after docking. * Restricted patient access, operation room space restriction and protecting patient from clashing robotic arms are concerns.

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CHFG – Clinical Human Factors Group – working with clinical professionals and mangers to make healthcare safer

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CHFG – Clinical Human Factors Group – working with clinical professionals and mangers to make healthcare safer

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We are a charity of clinicians and experts driven to improve patient safety

The Clinical Human Factors Group was set up by Martin Bromiley after his late wife died needlessly following a routine operation. Ten years on, the Charity has influenced a generation of workers by promoting the application of Human Factors science in all areas of healthcare. The NHS continues to have 150 preventable deaths per week. But there's more to do.

Our Trustees and Ambassadors work in clinical practice and fields related to Human Factors, quality and learning. They stay on top of the latest developments and critically examine best practices, research and current thinking to ensure we stay on-mission.

Our mission is:

Design for safety. Embed Human Factors science into procurement, design and delivery of care.

Learn from success and failure. Encourage a just culture, better local investigations, so mistakes are not repeated and success is.

Educate and promote Human Factors in all healthcare settings

While Government, patient safety programmes, initiatives and groups come and go, the Charity continues to be recognised and trusted as independent and recognised group. We serve as a repository for resources, best practice, knowledge and organisational memory. We work across organisations, departments and disciplines and our independence allows us to raise the awkward questions and challenge mainstream assumptions.

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CHFG - Clinical Human Factors Group works with clinical professionals and managers to make healthcare safer. In 2015, after the death of wife Elaine Bromiley during a routine operation where errors where made, airline pilot Martin Bromiley founded the charity to learn from mistakes made and improve safety.

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RCS Surgical Care Team Guidance Framework.PDF

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Our surgical care team guidance aims to help employers, surgeons and other healthcare professionals develop models of care that utilise the surgical care team in a consistent manner. It sets out distinct extended roles within the surgical team, and outlines competencies, training and clear routes of entry into these roles. The ultimate aim of this work is to enhance the quality of patient care, patient experience and patient safety, to improve the effectiveness and efficiency of services, and to support the quality and experience of surgical training.

Read the guidance

You can read the Surgical Care Team Guidance Framework below. You can also access templates and resources for the clinical governance arrangements that help support a flexible modelling of the surgical care team that meets local needs.

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Surgical Care Team Guidance - Royal College of Surgeons

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Our surgical care team guidance aims to help employers, surgeons and other healthcare professionals develop models of care that utilise the surgical care team in a consistent manner. It sets out distinct extended roles within the surgical team, and outlines competencies, training and clear routes of entry into these roles.

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Create your own Local Safety Standards for Invasive Procedures | NHS Improvement

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Create your own Local Safety Standards for Invasive Procedures | NHS Improvement

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Create your own Local Safety Standards for Invasive Procedures | NHS Improvement

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Templates for NHS providers who need to develop their own set of Local Safety Standards for Invasive Procedures (LocSSIPs).

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The Smell of the Place

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The Smell of the Place Sumantra Ghoshal at World Economic Forum

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Faculty of Peri-operative Care

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Home - The Faculty of Perioperative Care

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The Faculty is available to all perioperative practitioners, including trainees, such as: Surgical Care Practitioners; Surgical First Assistants; and all those with similar titles involved in the delivery of high quality surgical care.

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The History & Future of Sutures | Johnson & Johnson | Johnson & Johnson

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The History & Future of Sutures | Johnson & Johnson | Johnson & Johnson

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ohnson & Johnson has been a pioneer in wound healing for almost 130 years, ever since the company created the world's first mass-produced sterile sutures in 1887.

We haven't rested on our laurels since then, either. We've kept innovating in the sutures space well into the 20th century, which has helped to transform surgery and elevate standards of care. (Fun fact: Ethicon, a Johnson & Johnson company, makes enough sutures each year to wrap around the world six times!)

We trace the fascinating story behind how sutures were created many ( many) years ago, and how they became an indelible part of our company's history-and future.

Photo courtesy of Johnson & Johnson Archives

A fateful speech changes the future of surgery

British surgeon Sir Joseph Lister-who helped introduce the concept of antiseptic surgery-gives a presentation at the Philadelphia Centennial Exhibition's Medical Congress that inspires medicated plaster maker Robert Wood Johnson to start Johnson & Johnson, aimed at furthering the cause of sterile surgery. "In those times, surgeons used to operate in their street clothes, and would carry the same instruments and dressings from patient to patient, not even cleaning them in between use," says Margaret Gurowitz, Chief Historian at Johnson & Johnson.

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Stitch in Time: 18 Fascinating Facts About the History of Sutures | Johnson & Johnson

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ohnson & Johnson has been a pioneer in wound healing for almost 130 years, ever since the company created the world's first mass-produced sterile sutures in 1887. We haven't rested on our laurels since then, either. We've kept innovating in the sutures space well into the 20th century, which has helped to transform surgery and elevate standards of care.

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Fundamentals of Anatomy and Physiology for Student Nurses - Edited by Ian Peate and Muralitharan Nair

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Fundamentals of Anatomy and Physiology for Student Nurses - Edited by Ian Peate and Muralitharan Nair

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Peate, Nair: Fundamentals of Anatomy and Physiology: For Nursing and Healthcare Students, 2nd Edition - Instructor Companion Site

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Fundamentals of Anatomy and Physiology: For Nursing and Healthcare Students, 2nd Edition

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1. 1Usher Institute for Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK

2. 2Edinburgh Medical School, University of Edinburgh

3. 3Simpson Centre for Reproductive Health, Royal Infirmary of Edinburgh

4. 5Department of Psychological Medicine, Royal Infirmary of Edinburgh

5. 6MRC Centre for Reproductive Health, University of Edinburgh

Correspondence to: SW Chan sarah.chan{at}ed.ac.uk

The Montgomery case in 2015 was a landmark for informed consent in the UK. Two years on, Sarah Chan and colleagues discuss the consequences for practising doctors

The Montgomery v Lanarkshire case of March 2015 1 drew fresh attention to informed consent. Nadine Montgomery, a woman with diabetes and of small stature, delivered her son vaginally; he experienced complications owing to shoulder dystocia, resulting in hypoxic insult with consequent cerebral palsy. Her obstetrician had not disclosed the increased risk of this complication in vaginal delivery, despite Montgomery asking if the baby's size was a potential problem. Montgomery sued for negligence, arguing that, if she had known of the increased risk, she would have requested a caesarean section. The Supreme Court of the UK announced judgment in her favour in March 2015. The ruling overturned a previous decision by the House of Lords, 2 which had been law since at least the mid 1980s. 3 It established that, rather than being a matter for clinical judgment to be assessed by professional medical opinion, a patient should be told whatever they want to know, not what the doctor thinks they should be told.

Many organisations (in particular the General Medical Council, who intervened to make submissions in the case) said that the Montgomery decision had simply enabled UK law to catch up with current GMC guidance; others hailed it "the most important UK judgment on informed consent for 30 years." 4 Doctors have expressed their concerns about its potentially radical effects on patient care and clinical practice. 5 We held a public debate in 2015, including doctors, lawyers, and medical students, which showed renewed tension between the professional discretion of doctors and patients' choices 6; indeed, the verdict has been characterised as supporting patient autonomy over medical paternalism. 3 7 8 9 But what are the implications for doctors' practice and their legal liability? Two years after the Supreme Court's decision, we examine the effects of the Montgomery ruling on clinical and medicolegal practice.

Response to the ruling

Some clinicians said that retrospective application of the judgment could "open the floodgates" for claims in relation to doctors' past actions. 10 Others thought that the Montgomery ruling was unlikely to have this effect, however "excited the claimant law firms might become initially." 11 Legal opinions were reserved, describing the ruling as "the belated obituary, not the death knell, of medical paternalism." 12 Some argued that the standard imposed by the Montgomery decision merely reflected good practice as already specified by the GMC 13 and would make little practical difference to clinicians. 8 Nevertheless, the concern generated by the ruling might affect doctors' behaviour and other potential cases. Others have raised questions about the implications for the legal treatment of clinical judgment, suggesting that it represents "a radical move away from English law's traditional respect for clinical expertise." 9

Doctors at the coalface have received little official direction on how their practice should change in light of the ruling. We have heard anecdotally that some hospitals are in the process of updating their procedures on informed consent, but few have completed this. Although the Medical Defence Union and the Medical Protection Society have each issued statements and updated their guidance, as have some royal colleges (such as the Royal College of Surgeons), other bodies such as the GMC and the Royal College of Obstetricians and Gynaecologists (RCOG) have yet to do so.

RCOG's difficulty in providing guidance perhaps reflects the unique nature of obstetrics-essentially helping two patients through a normal and inevitable physiological process. A further challenge is that the risks of birth can change dramatically and quickly, making detailed discussion and informed decision making difficult. These "emergencies" might be exempt from the Montgomery ruling, depending on their nature and timing, but complications of labour (such as sudden and profound fetal distress or major maternal haemorrhage) are not, even though, as was noted in the judgment, choices about management of labour cannot generally be deferred. GMC guidance says that the consenting process is not a snapshot but an ongoing process. Planning for labour emergencies is essential, so that the doctor and patient can discuss the patient's wishes if an emergency should arise.

RCOG has proposed pilot programmes to identify what resources women, clinicians, and health services need to comply with the Montgomery ruling. Training and educational materials must be fit for purpose. Obstetricians urgently need guidance.

Legal consequences for doctors

The Montgomery decision redefined the standard for informed consent and disclosure. Previously, the Bolam test 14 in England and the Hunter v Hanley test 15 in Scotland were used to determine what should be disclosed. These tests ask whether a doctor's conduct would be supported by a responsible body of clinicians. The Bolam test was affirmed in Sidaway v Bethlem Royal Hospital Governors and others, 2 although the ruling was not unanimous, with judges placing different weight on the patient's right to make informed treatment decisions versus the doctor's professional judgment in disclosing information. The Montgomery case firmly rejected the application of Bolam to consent, establishing a duty of care to warn of material risks. The test of materiality defined in the Montgomery ruling was whether "a reasonable person in the patient's position would be likely to attach significance to the risk, or the doctor is or should reasonably be aware that the particular patient would be likely to attach significance to it." 1 The solicitor representing Montgomery spoke of the decision as having "modernised the law on consent and introduced a patient focused test to UK law." 16

Retrospective cases

Constitutionally, the Supreme Court cannot make new law; it can only state what, in theory, the law has always been. Doctors may have been treating patients as they understood the law to be, as in the Sidaway case, but the Supreme Court has told us that this was wrong 3 and that anyone who practised according to Sidaway was also wrong.

In practical terms, the ruling should apply at least back to 1999, when Montgomery saw her obstetrician. Guidance in effect at that time from the GMC, 17 BMA, 18 NHS, and the Scottish Office 19 supported a doctor's duty to disclose relevant information and risks. So the Montgomery principles have been known-or should have been known-by doctors for many years.

Since the Montgomery ruling, several attempts have been made to introduce a consent based claim to cases that were under way before the decision. One such attempt in Scotland has, so far, been unsuccessful. 20 Two English cases have allowed consent claims to be added after the Montgomery decision. 21 22 Some cases have succeeded on a Montgomery basis 23; we (AA) understand that others have settled before litigation ever started or was concluded, as the claims were unanswerable in the light of Montgomery. We (ESC) have noticed that a considerable proportion of cases of obstetric negligence raised since Montgomery involve consent in addition to standard complaints of substandard care. These issues are not always pursued, but obstetric litigation practice has noticeably changed, making professional training and clarity with respect to guidelines an even higher priority.

Subsequent cases

Looking at some of the cases in which the Montgomery ruling has been considered tells us about its interpretation to date. In Spencer v Hillingdon NHS Trust (April 2015) 23 the patient had bilateral pulmonary emboli after a hernia operation. He did not seek treatment immediately because he had not been advised of the risk of deep vein thrombosis or pulmonary embolism or of symptoms that might indicate these. The judge considered the Montgomery ruling and found that failure to inform the patient was a breach of the duty of care.

Shaw v Kovac (October 2015) 24 concerned a patient who died in 2007 after a transaortic valve implantation, which was then still the subject of clinical trials and not fully approved. The claimant's argument sought to use the Montgomery ruling to ground a claim for damages for the loss of life without informed consent. The court rejected this, holding that the Montgomery ruling did not create a right to informed consent as an independent cause of action, but simply set a new legal standard for the duty to disclose.

In Mrs A v East Kent Hospitals University NHS Foundation Trust (April 2015), 25 the claimant's baby, who was conceived using intracytoplasmic sperm injection, had a chromosomal abnormality. The claimant alleged that the trust was negligent in failing to advise of this possibility. The court applied the Montgomery test and decided that the risk was not material, because neither a reasonable patient nor the patient herself would have attached significance to it. Thus, although the test is focused on patients, doctors are not liable for every omission of disclosure to which a patient later objects." 25

Clinical concerns and ethical arguments

Some doctors feared that more stringent disclosure requirements would risk overwhelming patients with information, causing distress or leading them to make poor decisions, while doctors' time would be taken up with lengthy explanations, creating a drain on healthcare resources. Information overload is unlikely given that information should be tailored to the patient. But doctors must judge what is appropriate for each patient and how their exercise of judgment might be assessed by the courts. The doctor might think that disclosure of certain information could lead the patient to a decision that is not in their best interests, as was true for the Montgomery case. But the ethical and legal position is clear: doctors must not withhold information simply because they disagree with the decision the patient is likely to make if given that information.

Making sure that patients understand all the information they need to make a decision will inevitably take longer. But allocation of health resources should be tackled systematically rather than individually. Healthcare policy should cover, for example, which treatments should be available and how consent procedures should be handled. 17 The doctor's duty is simply to treat patients according to their interests, which might include being given more information than usual.

A second concern was that the ruling would encourage "defensive medicine," shifting the focus from helping the patient to protecting the doctor. But doctors should have already been following GMC guidance, which highlights the importance of communication. 13

Finally, doctors criticised the focus of patient autonomy over medical paternalism. But this is a false dichotomy-the idea of a fully autonomous patient making choices completely independent of the doctor's input does not reflect the complex reality of medical decision making, nor does the caricature of a paternalistic doctor riding roughshod over patients' objections.

Patients are not always aware of the facts of their treatment after consent related discussions, 26 and they are influenced by the way in which information is presented (the "framing effect"). 27 But the difficulties of conveying information about treatment and risks should not be taken to indicate that patients are incapable of understanding medical information or that patient autonomy in decision making is meaningless. Rather it shows that the communication process has a strong influence on how patients understand, remember, and evaluate information-all of which are essential to informed consent. The doctor's role is to ensure that relevant information is presented to enable the patient to use it meaningfully.

Conclusions

The Montgomery case was framed as a clash of values-patient autonomy versus medical paternalism. In reality, medical decision making involves a nuanced negotiation of information. Today's patients can expect a more active and informed role in treatment decisions, with a corresponding shift in emphasis on various values, including autonomy, in medical ethics.

The full implications of the case are undoubtedly still unknown, but Montgomery has clear relevance for medical law and ethics. Legally, consent law has been clarified and aligns with current GMC guidance, and the Montgomery test has already been applied in several cases. Ethically, it clarifies the existing shift towards a more cooperative approach in the consultation room. The Montgomery ruling has not radically changed the process of consent; it has simply given appropriate recognition to patients as decision makers.

Contributors and sources: The authors were organisers (ET, WW, JEN) and participants (SWC, AS, ESC) of an event in the Edinburgh Medical Debates series on the ethical and legal impact of the Montgomery case. 6 ET is a medical student at the University of Edinburgh and was primarily responsible for research and initial drafting of the manuscript; SWC is a researcher in bioethics and was responsible for subsequent drafting, critical revisions, ethical analysis, and part of the legal research; ESC, WW, and JEN are clinicians and were responsible for conceiving the idea for the manuscript, critical revisions, and obstetric medicolegal advice; AS is a barrister and QC in both Scotland and England, specialising in medical negligence, and was responsible for legal advice, analysis, and critical revisions. All authors approved the submission of the manuscript. SWC and JEN are the guarantors.

Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: AS represented the GMC in the Supreme Court in the Montgomery case. All other authors have nothing to declare.

Provenance and peer review: Not commissioned; externally peer reviewed

Footnotes

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

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Montgomery and informed consent: where are we now?

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1Usher Institute for Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK 2Edinburgh Medical School, University of Edinburgh 3Simpson Centre for Reproductive Health, Royal Infirmary of Edinburgh 5Department of Psychological Medicine, Royal Infirmary of Edinburgh 6MRC Centre for Reproductive Health, University of Edinburgh Correspondence to: SW Chan sarah.chan{at}ed.ac.uk The Montgomery case in 2015 was a landmark for informed consent in the UK.

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The surgical first assistant: are you compliant?

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The surgical first assistant: are you compliant?

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http://learn.genetics.utah.edu/content/cells/scale/