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Theatre sister develops unique guide to avoiding 'never events'

Cardiac nurse has compiled equipment guide to help colleagues avoid serious implant mistakes

A cardiac theatre sister has developed what is believed to be the first guidance for theatre nurses to help them prevent ‘never events’.

Minija Joseph with the manual

King’s College Hospital London sister Minija Joseph wrote the manual to help cardiac theatre nurses identify the different types and sizes of equipment for heart surgery, and to prepare them. The illustrated manual details every aortic, mitral and tricuspid valve and all repair devices.

The guidance is intended to reduce the risk of nurses implanting the wrong device – the type of never event that the NHS is working to eliminate.

There were 1,188 never events in the NHS in England between April 2012 and December 2015, including patients being given the wrong type of implant.

Ms Joseph, who has worked at King's College Hospital NHS Foundation Trust since 2007, developed her own rudimentary manual years ago. As colleagues increasingly commented on its usefulness, she contacted a cardiac device manufacturer to develop the guide, which will now be sent to cardiac centres around the world.

She said: ‘There are hundreds of surgical cardiac devices in an array of sizes, all with different preparation instructions.'

King's director of nursing Geraldine Walters said: ‘This is a wonderful example of a nurse going the extra mile to safeguard patients – both in the trust and further afield.'

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