In October 6th 2017, I was the scrub nurse in a never event at a UK Hospital Trust. The Trust could have punished us and taken an ‘archaic’ blame approach, instead of this they showed us respect and allowed myself, with the support at executive level, to introduce the ‘below ten thousand’ concept. This is known locally as 10,000 feet.

This concept allows anyone in theatre to impose ‘the sterile cockpit’ at critical times, by simply calling “10,000 feet”. The concept is a patient focused harm free concept. The secret of this concept is the fact that it works without using it! People are now more than aware that there is a ‘Standard Operating Procedure’ now in place which addresses any distractions employees are responsible for. By simply having it in place we are seeing a massive improvement with the compliance of Checklists.

After several months we are now analysing results. We don’t have enough evidence yet but we can say at the Trust we have seen the number of incidents reduce and quality of work improve. These outcomes will be discussed in the coming weeks.

Other hospital Trusts are now contacting us to discuss our response to the never event as it now being discussed in senior NHS circles, as the Just Culture being used to its most effective.

My vision after the never event was to help stop further incidents in the NHS. This is my coping mechanism for being involved in a serious incident. This concept is now growing in recognition and is present in Holland, Ireland, USA, India, Australia and now the UK.

I have written a presentation which I have delivered with success to many local forums. The presentation illustrates the never event I was involved in. The system approach enforces that human error did occur but the systems in place to protect our patients were weak.  Anyone’s thoughts on this are very much welcomed, both positive and negative.

For further reading please go to the Journal of Perioperative Practice article

Thank you for reading,

Robert Tomlinson RGN