| SURGICAL/INVASIVE PROCEDURE EVENTS | 17972 | 3214 | 1/1/2014 7:00:00 AM | Surgery | United States of America | | Minnesota Hospital Association and Minnesota Department of Health (USA) | This alert discusses the patient safety incidents related to surgery. Key findings of root causes of wrong site surgeries and wrong surgeries /procedures are provided.
In the 10 years that Minnesota has been collecting data on adverse health events, wrong site surgeries/invasive procedures have been among the most commonly reported events. In 2013, the number of wrong site surgeries/invasive procedures decreased by more than 35 percent, the lowest point since 2005. A decrease achieved in 2012 in wrong site surgeries/invasive procedures in radiology was maintained in the current year. Only two cases of wrong site surgery occurred in radiology this year, compared to five in 2012. Much of this decrease can be attributed to the continued work on the ‘SAFE SITE 2 0’ radiology roadmap. Of the reported wrong site surgeries/invasive procedures this year, 50 percent were left vs right procedures. This was often related to not having a consistent process for visualizing the site mark and verbalizing where it is located during the Time Out process. Root causes for wrong site surgeries included:
- A structured Time Out not in place for procedures conducted outside the operating room;
- Lack of multiple Time Outs when multiple procedures are being completed involving different staff members; and
- Failure of designated staff to visualize site mark during Time Out process.
The number of wrong surgeries/invasive procedures decreased by 39 percent. Seven of the events involved incorrect implants being placed during procedures. Four of the seven were incorrect lens implants during cataract procedures. This is a 50 percent decrease from 2012 in incorrect lens implants. Root causes for wrong procedure events included:
- Lack of standardized scheduling/ordering process;
- No standard process for implant verification;
- The process of verification did not include review of consent form.
Although good progress is being made in reducing the number of surgical patient safety events, best practices still need to be consistently applied. | | | 7/22/2015 5:52:00 PM | mauvais site, mauvaise procédure, chirurgies sur le mauvais patient, interventions invasives sur le mauvais patient, délai d'attente, marquage du site, guide de radiologie SAFE | | https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx | | False | | | Surgical Care Safety;Surgical Site Infection (SSI);Surgical Incidents;Retained Foreign Object;Patient Safety Incident;Surgical Safety Checklist |
| Complications from surgical drain tubes | 18053 | 3136 | 1/1/2014 7:00:00 AM | Surgery | Australia | | Victoria Department of Health (Australia) | This alert discusses patient safety incidents which involved post-operative complications associated with the use of various surgical drain tubes for wound drainage.
A number of patients suffered complications attributed to securing, removing and/or shortening of drain tubes. A small number of patients were discharged home with either a retained drain tube or small fragments of a drain tube retained during removal that remained undetected prior to discharge.
All patients underwent further investigation, readmission, and surgical intervention for removal of the drain tube (or fragment).
Contributing factors to the incidents were identified:
· The method used to secure the wound drain at the time of insertion was not effective causing it to become easily dislodged during wound management.
· Unrecognised damage to the drain tube on insertion may have caused the drain tube to fracture on removal and the tendency for part of the drain tube remaining undetected within the patient.
· The drain tube was not secured externally following routine shortening.
· In some instances there were delayed escalation of the missing drain tube to the surgical team for the following reasons:
i) unclear documentation of drain tube management;
ii) non-familiarity with the type of wound drains or drainage tube.
iii) lack of protocol for escalation and investigation of any missing/displaced surgical object.
Recommendations to prevent similar patient safety incidents were provided. | | | 7/22/2015 5:51:45 PM | complication post-opératoire, soins des plaies, drainage des plaies, traitement des plaies, rétention de corps étrangers, intervention chirurgicale, gestion du tube de drainage | | https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx | | False | | | Surgical Care Safety;Surgical Site Infection (SSI);Surgical Incidents;Retained Foreign Object;Patient Safety Incident;Surgical Safety Checklist |
| Surgical Fires: Trends Associated with Prevention Efforts | 17750 | 169 | 12/1/2012 7:00:00 AM | Surgery | United States of America | | Pennsylvania Patient Safety Authority (USA) | This alert discusses the patient safety incidences of fire on the operating field within a surgical suite. Fires on the operating field are dangerous to patients and providers. The Pennsylvania Patient Safety Authority did an analysis of reports of surgical fires in its database for the primary purpose of determining if surgical fires continue to be a problem, as identified by the Joint Commission , or if facilities have responded to advisories on prevention, such as those proposed by the American Society of Anesthesiologists. Analysts identified reports of fires submitted over seven years that occurred in the operating room on the surgical field and involved combustion resulting from a combination of heat, oxygen, and fuel. Seventy events that met the analysts’ definition of fires on the operating field were reported in the seven years between July 1, 2004, and June 30, 2011. Over
the past four years for which data was available, the rate of surgical fires has varied from 0.63 per 100,000 operations (1 per 157,545 operations) in the academic year 2007-2008 to 0.32 per 100,000 operations (1 per 309,305 operations) in the academic year 2010- 2011. One-third of the reported events indicated harm to the patient. Risk to providers, rather than patients, was cited in 6% of reports. Of the 65 reports with information about the ignition source, the source of ignition was an electrosurgical unit (Bovie unit) in 38 reports (58%), a fiberoptic light cord in 25 reports (38%), and a laser in 2 reports (3%).
Surgical fires remain a significant enough risk to justify use of a Fire Risk Assessment Score and adherence to the recommendations of the American Society of Anesthesiologists Task Force on Operating Room Fires and those of the Anesthesia Patient Safety Foundation.
Recommendations to prevent similar patient safety incidents are provided. | | | 7/22/2015 5:50:41 PM | electro-surgical active electrodes (Bovie units), lasers, fiberoptic light cord, surgical lights, nasal cannula, oxygen tubing | | https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx | | False | | | Surgical Care Safety;Surgical Site Infection (SSI);Surgical Incidents;Retained Foreign Object;Patient Safety Incident;Surgical Safety Checklist |
| Retained Objects in Gynecological Surgical Procedures Alert | 17669 | 89 | 7/24/2012 6:00:00 AM | Surgery | United States of America | | Minnesota Hospital Association and Minnesota Department of Health (USA) | This alert discusses patient safety incidents involving retention of foreign bodies after a gynecological surgical procedure. Since 2010, over a quarter (27%) of retained foreign objects have been related to GYN procedures performed in the operating room. The majority (40%) of the objects were retained following hysterectomy procedures; 20% were related to suburetheral sling procedures.
Vaginal packing was the most common (53%) item retained. Other items retained included: sponges; KOH ring instrument and balloon; plastic centering tab; and ultrasound transducer protective sleeve.
Findings from root cause analyses indicate that the most common (73%) reasons for the retention were issues related to communicating the presence of packed items to the next level of care and accounting for items being intact when removed or after use.
Recommendations to prevent similar patient safety incidents are provided. | | | 7/22/2015 5:52:15 PM | corps étrangers, hystérectomie, fronde sousurétrale, tamponnement vaginal, ballonnet et bague KOH, languette de centrage de plastique, protection de la sonde d'échographie | | https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx | | False | | | Surgical Care Safety;Surgical Site Infection (SSI);Surgical Incidents;Retained Foreign Object;Patient Safety Incident;Surgical Safety Checklist |
| Retained or Broken Orthopaedic Surgical Equipment in Patients | 18732 | NSW38 | 7/1/2009 6:00:00 AM | Surgery | Australia | | New South Wales Department of Health (Australia) | "A number of patient safety incidents where orthopaedic material has been retained, or surgical equipment has broken off during a surgical procedure were reported to the NSW Health. Any retained material or surgical equipment requires a second procedure to remove the material which could contribute to further patient harm. Actions to reduce risk have been included in this Safety Notice." | | | 7/22/2015 5:53:49 PM | Unintended retention of a foreign object in a patient after surgery or other procedure Surgical Events Objet étranger oublié dans le corps du patient après la chirurgie ou autre | | https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx | | False | | | Surgical Care Safety;Surgical Site Infection (SSI);Surgical Incidents;Retained Foreign Object;Patient Safety Incident;Surgical Safety Checklist |
| Retained surgical instruments and other materials after surgery | 19345 | HK043 | 9/1/2010 6:00:00 AM | Surgery | Hong Kong | | Hong Kong Hospital Authority | "The most commonly retained instruments are fragments or broken parts of instruments, stapler components, parts of laparoscopic trocars, guide wires, catheters, pieces of drains, malleable retractors and consumables. Contributing factors include instrument count not performed or some instruments have not been included in the count, proceduralist unfamiliar with the equipment or instruments, lack of formal review processes fro the introduction of new equipment and technologies, consumables not easily identified once blood-soaked, and staff being distracted or diverted and failing to identify retained surgical items. This alert includes actions to reduce risk." | | | 7/22/2015 5:52:32 PM | Unintended retention of a foreign object in a patient after surgery or other procedure "verres needle sheath, ureteral patency device, retained swabs Surgical Events | | https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx | | False | | | Surgical Care Safety;Surgical Site Infection (SSI);Surgical Incidents;Retained Foreign Object;Patient Safety Incident;Surgical Safety Checklist |
| Watch Out for Bulbs - High Risk of a Retained Surgical Item | 17946 | 3237 | 5/1/2014 6:00:00 AM | Surgery | United States of America | | Oregon Patient Safety Commission (USA) | This alert discusses the patient safety incidents of retention of foreign bodies following surgical procedures. Two incidents have been reported and one is described in detail.
In the most recent Oregon case, a vaginal bulb was considered a countable item and was listed on the count board. The bulb is inserted into the vagina to assure that air remains in the abdomen during the procedure. The bulb was reported as removed as the procedure was ending, but no staff member recalls actually seeing the bulb removed. Retention of the bulb was discovered a week and a half later when the patient checked in to the emergency department with symptoms of infection. The hospital noted a communication breakdown as contributing to the event, but the reasons for that breakdown were unclear. Since the item was listed on the count board and was noted as having been removed, staff assumed that the item had been safely taken out, but obviously the assumption was incorrect. Given the complex nature of operating room processes, time pressures and interruptions may have also contributed.
Recommendations to prevent similar patient safety incidents are provided. | | | 7/22/2015 5:52:07 PM | corps étranger laissé dans le corps, objet chirurgical laissé dans le corps, laparoscopie, objet dénombrable, tableau de dénombrements, procédures complexes, contraintes de temps | | https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx | | False | | | Surgical Care Safety;Surgical Site Infection (SSI);Surgical Incidents;Retained Foreign Object;Patient Safety Incident;Surgical Safety Checklist |
| Mitigating surgical risk in patients undergoing hip arthroplasty for fractures of the proximal femur | 19708 | NPSA086 | 3/11/2009 6:00:00 AM | Surgery | England and Wales | | National Health Service Commissioning Board (England and Wales) | A high number of planned total hip replacements and repairs of hip fractures are performed yearly in the UK. However, the mortality rate following partial hip replacement after fracture treatment is ten times higher than with a planned hip replacement. This Rapid Response Report outlines the risks of sudden intraoperative death associated with partial hip replacements, specifically in emergency situation. The most common cause of death during the procedure is the occurrence of a venous embolism. Fat and marrow contents are dislodged during the procedure and inadvertently travel to the patient's lung causing respiratory distress. This condition is enhanced by poor patient preparation, dehydration, and comorbidities and has been also associated with cement insertion. This report outlines actions to reduce the risk and make a risk/benefit assessment. | | | 7/22/2015 5:53:41 PM | ciment chirurgical, chirurgie, chutes, fracture de la hanche | | https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx | | False | | | Surgical Care Safety;Surgical Site Infection (SSI);Surgical Incidents;Retained Foreign Object;Patient Safety Incident;Surgical Safety Checklist |
| Two patients were unexpectedly hospitalized following procedures at ambulatory surgery centers | 17729 | 147 | 10/1/2010 6:00:00 AM | Surgery | United States of America | | New Jersey Department of Health and Senior Services (USA) | This alert describes two patient safety incidents related to lack of an of NPO (nothing by mouth) after surgery. Two patients were unexpectedly hospitalized following procedures at ambulatory surgery centers. One patient appropriate medical history and insufficient patient education on the meaning developed wheezing and stridor; the patient failed to mention a recent diagnosis of asthma and prescribed inhaler. The second patient vomited and aspirated immediately post-op; he had failed to follow the (NPO) no eating/drinking/ medication instructions prior to the procedure.
It was determined that the cause of the incidents was a failure to identify important information related to the patients’ procedures. Some of the information should have been revealed during a thorough medical history and some should have been more effectively provided to the patient to ensure they understood their procedure and the care required thereafter.
Two strategies for preventing this type of patient safety incident are provided. | | | 7/22/2015 5:50:32 PM | postop, postopératoire, post-chirurgie, antécédents médicaux, éducation des patients, évaluation préadmission, questions ciblées, consignes RVO, rien par voie orale, aucune | 6 | https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx | | False | | | Surgical Care Safety;Surgical Site Infection (SSI);Surgical Incidents;Retained Foreign Object;Patient Safety Incident;Surgical Safety Checklist |
| Electrosurgery Safety Issues | 19072 | PA054 | 3/1/2006 7:00:00 AM | Surgery | United States of America | | Pennsylvania Patient Safety Authority (USA) | "Between 2004 and 2006, approximately 170 reports of surgical fires, related to the use of electrosurgery, resulting in burns to patients and staff have been reported. Fire requires three elements: an ignition source, oxidizers, and fuel. In most cases, surgical fires and burns can be significantly reduced or eliminated by instituting and following some basic principles of electrosurgical safety. More than half of electrosurgical unit (ESU) related burns and fires are attributable to inadvertent ESU activation. This alert describes actions to reduce risk." | | | 7/22/2015 5:54:16 PM | Surgical Events "brûlures, incendies, oxygène, électrodes, alcool, préparation cutanée, coagulation, appareil d'électrochirurgie, étui, ciment osseux, escarre, bijoux | | https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx | | False | | | Surgical Care Safety;Surgical Site Infection (SSI);Surgical Incidents;Retained Foreign Object;Patient Safety Incident;Surgical Safety Checklist |
