Interestingly, these are exactly the same factors that are involved in the majority of aeroplane accidents which happened in the 1970s. illustrated here by the worst aviation accident of all time in tenerife in 1977 when two Boeing 747s crashed into each other on the runway killing 583 people.
Sign in confirmation of pt id,consent,site marking,check for allergies and concerns Time out confirm patient,site,procedure,position,application of infection bundle,dvt prophylaxis,correct imaging Sign out confirm procedure performed and instrument and swab counts and plans for post op management.
73 year old female had witnessed collapse at around
Brought in by ambulance to primary hospital at
Glasgow coma scale of 6/15, hypertensive,
Patient airway secured, intubated, ventilated by
accident emergency team and transferred for CT Scan
Scans reviewed in view of clinical scenario.
Patient accepted and plan for Burr hole evacuation of
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
Transfer letter with CT scan head on CD made
Patient identified and proposed surgical plan
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.
Surgical consultant informed.
Two more burr holes made.
Patient transferred to ICU intubated and ventilated.
Patient extubated after seven days with reasonable
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.
General Surgery 20%
Maxillofacial, cardiovascular, otolaryngology and
Human Factors in Safety
Institutional controls/formal system
Lack of checklist
Reliance solely on surgeon.
unusual time pressure
pressure to reduce pre-op prep time
Unavailability of information
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
Can be devastating for patient and the operating