Safer surgery: update on current patient safety initiatives.
Abstract: Surgery is an essential component of healthcare worldwide. However in industrialised countries, major complications occur in 3-16% of all inpatient surgical procedures, with permanent disability or death rates affecting approximately 0.4 - 0.8% of patients (Haynes et al 2009).

KEYWORDS Safer surgery / NPSA / Patient safety
Article Type: Report
Subject: Perioperative care (Safety and security measures)
Anesthesia (Usage)
Anesthesia (Safety and security measures)
Surgery (Safety and security measures)
Health care reform (Evaluation)
Patients (Care and treatment)
Patients (Laws, regulations and rules)
Author: Watts, Fran
Pub Date: 10/01/2009
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2009 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: Oct, 2009 Source Volume: 19 Source Issue: 10
Topic: Event Code: 260 General services; 350 Product standards, safety, & recalls; 930 Government regulation; 940 Government regulation (cont); 980 Legal issues & crime Advertising Code: 94 Legal/Government Regulation Computer Subject: Government regulation
Product: Product Code: 8000410 Surgical Procedures NAICS Code: 62 Health Care and Social Assistance
Organization: Organization: World Health Organization
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 210725238
Full Text: Between April 2007 and March 2008, there were 135,247 incidents reported to the National Patient Safety Agency relating to surgical specialties in England and Wales. Dr Atul Gawande, lead for the World Health Organisation's (WHO) Safe Surgery Saves Lives campaign, has said that at least half of all adverse events that occur in surgery worldwide are avoidable (Gawande 1992).

The NPSA believes that by encouraging healthcare staff to be more open and report incidents to its Reporting and Learning System (RLS), learning can be achieved and subsequently avoidable harm to patients will be reduced. The RLS is therefore an invaluable resource for identifying the risks and system weaknesses which may not always be apparent at local levels.

The NPSA has a dedicated Anaesthesia and Surgery team which aims to improve patient safety in anaesthesia and surgery by working in collaboration with the frontline staff, healthcare organisations, relevant colleges and associations as well as other stakeholders. The learning identified from incidents reported to the RLS is used to prioritise the programme of work for the team.

One of the key mechanisms by which the Team fulfills its charter is through the Clinical Board for Surgical Safety which the Chief Medical Officer recommended to be established in his Annual Report 2007 (Donaldson 2008). The Board is a multi professional group including surgeons, anaesthetists, nursing bodies and other relevant professional organisations and meets on a quarterly basis. The purpose of this unique group is to facilitate a more inclusive, collaborative and coordinated approach to the strategic direction for patient safety in surgery. Operationally, the Board provides advice to the NPSA on priorities related to emergent surgical safety risks and the most appropriate methods of communication and dissemination of these risks, as well as monitoring the implementation status of previously released guidance.

The following section outlines the work in relation to surgery that the NPSA's A&S team is currently involved in.

Surgical Safety Checklist

Earlier this year the NPSA issued a Patient Safety Alert on using the WHO's Surgical Safety Checklist for every surgical procedure (NPSA 2009). Implementation has been led by the Patient Safety First Campaign in England and the 1000 Lives Campaign in Wales.

NHS organisations have until February 2010 to fully implement the Alert's recommendations.

In addition to this, the NPSA is working with the Royal Colleges of Ophthalmologists and Radiologists to refine the checklist so that it can support the needs of their specialist members. These are currently planned for release in early 2010.

Rapid Response Reports

Just over 1% (1,502) of the 135,247 surgical incidents reported to the RLS resulted in serious harm or death. Each of these incidents has been reviewed by clinical experts in the NPSA so that lessons can be learnt across the NHS.

If evidence of preventable and substantive risk is found during the incident reviews, the NPSA issues a Rapid Response Report which contains clear and specific actions for healthcare organisations to reduce harm.

The most recent reports relating to surgery that have been issued are:

Avoiding wrong side burr holes / craniotomy (November 2008)

This was based on evidence from 15 incidents of patients receiving surgery on the wrong side of their heads (through wrong side burr holes or craniotomies). Specific actions include marking the intended surgical site, having a time out prior to final positioning, inserting of head pins, auditing local practice and reporting further incidents.

Mitigating surgical risk in patients undergoing hip arthroplasty for fractures of the proximal femur (March 2009) This was based on evidence from 26 patient deaths and six cases of severe harm where bone cement was used during hip surgery. Most occurred during emergency hemiarthroplasties. The use of cement is indicated in certain clinical situations, however for all hip arthroplasties for proximal femoral fractures, clinicians should undertake a risk-benefit assessment to mitigate harm.

For more information on these, visit the NPSA website: rapidrr/

This following section outlines work under consideration and or in progress and will be subject to further discussion at the Clinical Board for Surgical Safety.

There are two Rapid Response Reports currently being developed:

Minimising the risks of using tourniquets for finger and toe surgery

This is based on evidence from 14 incidents between 2003 - 2009 where non inflatable tourniquets for finger and toe surgery have been left in situ and resulted in significant harm to the patient including further surgical treatment and amputation of the affected digit. Simple measures that have been suggested are the inclusion of the tourniquets to swab and instrument counts, using brightly coloured, easily identifiable commercial tourniquets and including the use of tourniquets to the Surgical Safety Checklist.

Reducing the risk of perforation during laparoscopic surgery

This is based on 91 reported incidents relating to perforations during laparoscopic surgery; 14 of which resulted in the patient death either during the procedure or postoperatively. Potential risk reduction strategies include review of the training and supervision of medical staff, post-operative care (including recognition of the signs of deterioration) and national audit.

Management of Tracheostomies

The NPSA issued guidance relating to 'Protecting Patients who are Neck Breathers' in March 2005 (NPSA 2005). This focused on the management of patients with tracheostomies and laryngectomies when requiring emergency care.

The NPSA continues to receive incidents related to tracheostomy management, so in collaboration with clinical experts the A&S team is now considering further guidance relating to safe tracheostomy care.

The NPSA's Anaesthesia and Surgery team will be at this year's AfPP Congress in October--stand number A38. They will be available to provide further information regarding any of the above or to discuss any other patient safety issues in anaesthesia and surgery.


Donaldson, L 2008 On the State of Public Health: 2007 Annual Report of the Chief Medical Officer London, DH

Gawande AA, Thomas EJ, Zinner MJ, Brennan TA 1999 The incidence and nature of surgical adverse events in Colorado and Utah in 1992 Surgery 126 (1) 66-75

Haynes AB, Weiser TG, Berry WR et al 2009 A surgical safety checklist to reduce morbidity and mortality in a global population New England Journal of Medicine 360 (5) 491-499

The National Patient Safety Agency 2009 Patient Safety Alert: WHO Surgical Safety Checklist London, NPSA

The National Patient Safety Agency 2005 Protecting Patients who are Neck Breathers London, NPSA

Correspondence address: Fran Watts, Surgical Lead, National Patient Safety Agency, 4-8 Maple Street, London, W1T 5HD.
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