Using Datix Data to Support Proactive Perioperative Safety
Summary
Barts Health NHS Trust transformed how Datix incident data is used to improve perioperative safety, moving beyond reactive Never Event reporting towards a proactive, intelligence-led approach to risk. Rather than focusing solely on serious incidents, the team redesigned Datix reporting to capture patterns across all invasive procedures, including near misses, process failures, and human factors concerns.
By linking Datix data to NatSSIPs 2 standards and combining incident reporting with observational “Work as Done” reviews, the organisation developed a richer understanding of where and how conditions for harm develop. This shifted incident reporting from a retrospective compliance process into a practical safety improvement tool capable of identifying organisational vulnerabilities before serious harm occurs.
The Challenge
Surgical and procedural Never Events include wrong site surgery, retained foreign objects, and incorrect implants. Historically, Datix was primarily used as a reactive reporting tool, focused on capturing Never Events for compliance purposes rather than identifying the underlying conditions that contribute to them and associated. Under the previous NatSSIPs 1 framework, safety was largely measured through Never Event rates and checklist compliance, reinforcing a culture of assurance rather than organisational learning.
As a result, many important safety signals – including near misses, process failures, communication breakdowns, and human factors concerns within the NatSSIPs standards – were either not captured consistently or not analysed in a meaningful way. Organisations had limited visibility of the warning signs that precede these incidents and little ability to identify patterns linked to specific standards, sites, specialties, procedures and associated gradings of harm.
The challenge was to transform Datix from a reactive reporting system into a proactive safety intelligence tool capable of identifying how perioperative risk develops and accumulates, enabling earlier intervention before serious harm occurs.
The Solution
The Group Patient Safety Team fundamentally redesigned how Datix data was configured, categorised, and interpreted across perioperative services. Reporting forms were restructured to capture richer, more consistent data across all invasive procedures, linked to the NatSSIPs standards and to harm gradings enabling meaningful analysis of near misses, standards and process failures, not just Never Events or serious harm.
In line with NatSSIPs 2, a proportionate classification approach was introduced to help identify lower-level incidents that, when viewed collectively, reveal emerging system vulnerabilities. Datix data was then integrated into a Power BI dashboard, allowing local incident patterns to be analysed alongside wider national intelligence and supporting more proactive horizon scanning.
The team also introduced targeted “Work as Done” observational visits in higher-risk areas to compare reported incidents with real clinical practice and identify where under-reporting or process variation may exist. By combining quantitative reporting data with qualitative observations, Barts Health developed a more complete picture of perioperative safety and strengthened its ability to identify risks earlier and intervene before harm escalated.
Results & Next Steps
Using Datix as a proactive intelligence platform has significantly changed how perioperative safety is understood and managed across Barts Health. By analysing patterns across all invasive procedure incidents rather than focusing solely on Never Events, the organisation can now identify recurring vulnerabilities earlier and target improvement work before serious harm occurs. Datix insights are routinely used to support safety improvement activity at ward, specialty, and site level.
The move to more structured and proportionate reporting has revealed previously hidden themes linked to near-miss events in linked to certain NatSSIPs standards. This has supported more targeted, systems-based interventions while strengthening staff confidence in reporting by making incident reporting feel more meaningful and action-oriented.
The methodology developed at Barts Health has also influenced national perioperative safety guidance through CPOC and has been shared widely through NHS safety networks and conferences as a scalable model for using Datix data more proactively. Overall, the approach has shifted focus from retrospective investigation towards earlier identification of risk and more preventative system safety work.
