Litany of surgical blunders revealed

Health Editor,Jeremy Laurance
Monday 14 July 2008 00:00

The cases of 14 brain surgery patients who were the victims of catastrophic errors when neurosurgeons operated on the wrong side of the head are to spearhead a government drive to make operations safer.

Sir Liam Donaldson, the Government's chief medical officer, will highlight the cases at the launch of his annual report today when he will announce the establishment of a new clinical board for surgical safety to reduce errors and eliminate "wrong site" mistakes.

About 7.9 million operations are performed in Britain each year, nearly 10 times the number of births, yet surgical safety attracts far less attention than the safety of maternity care.

In 2007 more than one operation a month – 16 in all – was done on the wrong site. Examples include knee replacements on the wrong (healthy) knee, cochlear implants – surgically implanted hearing aids – in the wrong ear, removing bone from the wrong foot and wrong incisions to gain access to organs in the abdomen.

One patient a day was listed for the wrong operation in 2007, and there were 1,136 errors involving operating lists, including mistaken surgery, wrongly identified patients or operations performed in the wrong place.

The 14 brain surgery patients had suffered head injuries causing bleeding in the brain leading to increased pressure in the head. The standard treatment is to drill holes in the skull to release the pressure, but in the 14 cases the "burr-holes", were drilled on the wrong side. A second set of burr-holes then had to be drilled on the correct side. The 14 cases, all in the UK, were reported to the National Patient Safety Agency over the past three years.

Sir Liam told The Independent: "The procedure of drilling burr-holes can be life-saving and you could say that it is a low number [drilled on the wrong side] in the context of all neurosurgical cases. But many people would be incredulous that it could happen at all, let alone be repeated. It is a challenge to our ability not just to reduce error but to ensure these sorts of error do not happen. They should be 'never events'."

In all, almost 130,000 errors involving surgical procedures were reported to the National Patient Safety Agency. In most cases involving operating lists, the error will have been detected before the surgery was done so the true number of errors is likely to be under-reported.

Sir Liam said: "Most surgery is safe but errors do occur. Many are minor but some are serious. Some should be 'never events'. We really should be able to consign wrong-site surgery to the history books."

In a second example highlighting a different problem, he will describe 14 deaths and nine serious reactions among patients having hip replacements related to the cement used to fix the artificial joint. Hip replacements are among the commonest operations in Britain but in rare cases the cement causes globules of fat to be forced out of the bone into the blood, triggering a heart attack. In the UK, half of all hip replacements are performed using cement; in Canada just 3 per cent are. Guidance about the risks of cement had been issued to surgeons in the UK, but practice had not changed as quickly as it had in North America.

Sir Liam said: "No one knows what causes this reaction."

Two weeks ago, NHS Review by Lord Darzi, the surgeon and Health minister, called for the safety and quality of health care to be placed at the heart of the NHS and said urgent steps should be taken to eliminate "never events", serious incidents which harm patients and damage public confidence in the service.

The new clinical board will be established by the National Patient Safety Agency and include the Royal Colleges of Surgeons and Anaesthetists and patient organisations. Its first task will be to tackle wrong-site neurosurgery and fatal reactions to cemented hip replacements.

Sir Liam will also call for safety tests based on a checklist to be piloted in all UK hospitals. Surgeons and nurses will run through the checks before each operation in the same way pilots check their aircraft before take-off. The Surgical Safety Checklist was launched by the World Health Organisation last month.

About 20,000 patients die after surgery each year in the UK but it is not known how many were preventable. An estimated 2,000 NHS patients die each year as a result of errors in treatment, and an inquiry by the National Audit Office in 2005 concluded that half of all incidents could have been avoided if staff had learnt the lessons of previous errors.

Although serious errors are rare, a study of 38 surgeons in 14 NHS hospitals in the British Medical Journal in 2006 found "most" had experience of operating on the wrong site.

"We should be able to make major in-roads into reducing surgical errors," Sir Liam said.

*Vaccines against the hospital bugs MRSA and Clostridium difficile (C diff) will be available in the next decade, the Government's chief medical officer has said. Professor Sir Liam Donaldson said immunising patients against the infections would be a "big breakthrough".

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