This month’s featured alerts focus is on surgical care safety, another clinical priority area for the Canadian Patient Safety Institute’s Forward with Four strategy. There are a number of surgical care safety alerts and recommendations found on Global Patient Safety Alerts that touch upon a number of key topic areas including: wrong-site surgery, retained foreign objects and complications associated with improper equipment use. Three specific alerts related to these themes are highlighted below:
The first alert is from the Hong Kong Hospital Authority and describes a patient safety incident where a scheduled ureterorenoscopy was performed on the wrong side (left instead of right) due to inadequate preparation, a lack of communication during patient handover and a missed opportunity for a surgical team member aware of the mistake to speak up prior to continuing with the procedure. This alert demonstrates how a number of factors, if unaddressed, can lead to this type of patient safety incident in the operating room.
Complex surgeries often require multiple healthcare professionals and teams. This alert from the Winnipeg Regional Health Authority describes a patient safety incident where an inadequate surgical count at changeover led to a retained surgical instrument in the patient’s pelvis that was discovered months later after significant abdominal pain had been reported.
Anesthesia awareness occurs when a patient becomes cognizant of some or all of the events during surgery while under general anesthesia. This alert from The Joint Commission describes actions related to equipment maintenance and maintaining effective policies/procedures to reduce the risk of this type of patient safety incident from occurring.
Surgical procedures are an essential part of providing effective healthcare but have also been demonstrated to lead to patient safety incidents if risk mitigation strategies are not properly implemented and followed. Currently, there are 231 alerts and 960 recommendations that can be assessed on Global Patient Safety Alerts. This is a wealth of knowledge that can be shared with your organization to reduce and prevent patient safety incidents related to surgical care.
For more information on becoming a contributing organization, please contact GlobalAlerts@cpsi-icsp.ca