Although surgery is generally very safe, a report by the Chief Medical Officer, Sir Liam Donaldson, has highlighted concerns that many inherent risks are not fully appreciated. The latest data published in the report shows that the National Patient Safety Agency received 129,416 reports of potential errors involving surgical procedures during 2007.
He commented: “The process of creating operating lists is complex, requiring an understanding of the patient in question, their diagnosis and suitability for the proposed procedure, logistical issues related to timing and the experience of surgeons required to operate. Junior medical staff, who are responsible for compiling the operating list, often lack understanding of the potential for error at each stage of the process.”
He added that the creation of operating lists is not standardised across the NHS with procedures varying from computerised systems relying on data entry clerks, to junior doctors manually entering patient details. Sophisticated independent checking mechanisms applied in other high-risk industries are rarely applied. This has led to errors such as patients receiving the wrong strength lens for eye surgery because the lists were changed at the last minute and the surgeons assumed they were operating on a different person.
According to Sir Liam Donaldson, the adoption of safer techniques in the UK has not kept pace with other countries, in certain areas of surgery. For example, in this country 50% of total hip replacements are performed using special cement to hold the whole prosthesis (artificial metal joint) in place. He pointed out that bone cement implantation syndrome (BCIS) can occur, following the use of cement in joint replacement operations, which can prove fatal in severe cases.
Several techniques to reduce occurrence have been suggested. These include thoroughly assessing high-risk patients and selecting the joint technique best for them, controlling pressure in the bone during the placement of cement, using advanced cementing techniques or opting for not using cement at all. Bone cement implantation syndrome only occurs when cement is used for hip replacements.
In contrast with the 50% of cases fully using cement in the UK, in Canada only 3% of operations are completed using cement for the whole joint. The National Patient Safety Agency National Reporting and Learning System recorded 14 deaths and nine serious reactions related to the use of cement in hip replacements in 2007. Guidance about the risk of cement has been conveyed to surgeons in this country, but change in practice has not occurred at the same rate as that in North America.
Sir Liam Donaldson called for urgent action to improve safety in surgery and outlined the following measures:
• The establishment of a clinical board for surgical safety.
• Routine use of the World Health Organization’s Surgical Safety Checklist before, during and after the operation.
• More use of risk scores to estimate the risk to patients before the operation.
• Regular collection and analysis of death rates 30 days after operations, which should be made available to the public.
He concluded: “Surgery for patients in this country is generally very safe, but we can and should make it even safer. Further improvements will need a more detailed understanding of how often errors occur, a change in culture and the use of innovative new tools, such as surgical checklists.”
Commenting on recommendations to improve the safety of surgery, Dr Jonathan Fielden, chairman of the BMA’s consultants committee said: “We strongly support measures designed to enhance patient safety and hope these new proposals will be used constructively to further improve the quality of patient care.”
