Identifying resilience: a system safety review of trauma and orthopaedic theatres.

A prospective, qualitative study, of trauma and orthopaedic theatres was undertaken using the CARe QI handbook and the SEIPS framework, with the aim of preventing future Never Events. The study demonstrated a new approach, focussed on understanding 'work as done' to identify opportunities to improve system resilience, tested, using the Model for Improvement. Undertaken during the Covid-19 pandemic, it demonstrates that such conditions should not be a deterrent to observational studies, but requiring greater time and resource than a standard investigation, the approach may not align with current organisational or regulatory expectations. At the conclusion of this study, the mean time between Never Events in theatres had increased from 46 to 224 days, an achievement that had not previously been possible using the regulatory required, safety I, investigatory approach. These findings should be used to inform future PSIRF and Never Event Frameworks, to ensure effective systems-based analysis and improvement.