Wahid Altaf

73 year old female had witnessed collapse at around 2200hrs.

Brought in by ambulance to primary hospital at 2300hrs.

Glasgow coma scale of 6/15, hypertensive, left hemiplegia.Patient airway secured, intubated, ventilated

by accident emergency team and transferred for CT Scan head.

Scans reviewed in view of clinical scenario.Patient accepted and plan for Burr hole

evacuation of subdural hematoma.Anesthetic team called in and patient handed

over with a plan to transfer.Transferred by anesthetic team in ambulance

at around 0300 hrs.

Received patient in operating theatre at 0400 hrs.

Anesthetic, Neurosurgical, Nursing team present at handover.

Transfer letter with CT scan head on CD made available.

Patient identified and proposed surgical plan confirmed.

Consent sought from next of kin.Patient placed for surgical procedure with

left side of head up by neurosurgical fellow.Head shaved by neurosurgical SHO.Two Burr holes made by Neurosurgical SpR.

Everyone in theatre stunned.

Surgical consultant informed.Two more burr holes made.Hematoma evacuated.Patient transferred to ICU intubated and

ventilated.Family informed.Patient extubated after seven days with

reasonable recovery.

Patient sustained a major, preventable error, which had minimal impact on the outcome.

It likely did, however, have a significant impact on the psychological comfort and confidence of patient’s family and operating team.

Surgery performed on wrong side or site of body, wrong surgical procedure performed and surgery performed on wrong patient.

Incidence 40 times a week in hospitals and clinics in USA consistent with 1300 to 2700 cases of wrong site procedures per year.

Orthopedic/Podiatric 41%General Surgery 20%Neurosurgery 14%Urology 11%Maxillofacial, cardiovascular, otolaryngology

and ophthalmolgy 14%.

Human Factors in Safety

AccidentCausation

Technical Factors

Human Factors

Organisational / SafetyCulture

OperatorBehaviour= +

(30-20%)

(70 -80%)

System factors Institutional controls/formal system Lack of checklist Reliance solely on surgeon. unusual time pressure pressure to reduce pre-op prep time Unavailability of information

Process factors Inadequate pt assessment Inadequate care planning Inadequate medical record review Miscommunication among team members Failure to include patient and family when

identifying correct site. Failure to mark the correct operation site. Failure to recheck pt information before

starting the operation.

Can be devastating for patient and the operating team.

Preoperative verificationSign inTime outSign out

1

Better verification process.Marking of surgical site by surgeon

responsible for surgery.Team briefing.Time out like national anthem.Necessity of displaying relevant imaging.

Primary responsibility relies on operating surgeon.

Individual professional responsibility of Anesthetist Scrub/Circulating/Anesthetic nurse.

Process relying on surgeon and surgical memory is doomed to ultimate failure……..

Don’t assume responsibility as we are equally responsible……..