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Krishna Moorthy: A lot of things can get forgotten in the operating theatre

I became a consultant a year ago and I do operations for cancer of the stomach and gullet – complex operations lasting six to eight hours on patients who are quite sick and have a lot of problems.

We are the pilot site for the Safer Surgery Checklist in the UK and we introduced it in two of our eight theatres in March. It is a huge culture change. An operating theatre can be an extremely busy and stressful place – turnover is quite fast and you have different people doing different things. A lot of things can get forgotten.

Even getting members of the team to introduce themselves can be embarrassing and feel awkward. But it is important to get the team talking to each other. There was a case a few years ago in Cardiff in which surgeons removed the wrong kidney. The medical student who was present knew it was wrong, but had felt unable to say anything.

The other day we had a patient in theatre who had had an earlier hip replacement. The assistant anaesthetist noticed that the pad for the diathermy machine [used to seal blood vessels] was on the wrong side [with a risk of an electrical short from the metal in the hip]. So we changed its position.

Some of the surgeons complained we were focusing too much on wrong-site surgery when it was such a rare problem – 0.003 per cent. But I argued that is 2,500 cases in the US, where they do 75 million operations a year. If you extrapolate that to the US airline industry with 10 million flights a year, that is equivalent to one crash a day.

We often say in surgery that something is too rare for a profession like ours – but if you look across the population it amounts to a lot. We can't say we need to reduce wrong-site surgery. We need to completely eliminate it.

A checklist does three things. It ensures the things that must be done have been done – like checking you have got the right patient and the right site for the operation. It ensures the minimum expected steps in complex processes are carried out. And it enables the team to talk to each other so everyone knows what is to be done and if there are any deviations.

The writer is a consultant surgeon at St Mary's Hospital, London

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