Focus on patient safety - "Surgical safety. A quick check is better than a big shock!"

Context  

Despite the great lengths medical teams go to to improve the safety of surgical practices, mistakes are still being made. 

In fact, the HAS recorded 26 especially serious events in the database containing feedback from the care-related serious adverse events reporting system in which the wrong side, site or location were operated on or medical equipment was left behind. In the physicians accreditation database, we found 356 serious adverse events related to incorrect use of the check-list (CL).  

These figures undoubtedly do not reflect reality, since not all events are reported.  

Objective 

By sharing this feedback from professionals faced with these care-related serious adverse events, this information sheet can be used to alert and raise awareness among theatre teams and medical teams as to the occurrence of serious adverse events which could otherwise have been avoided had the theatre check-list been used properly, and to involve them in adapting the CL to their practices so they can use it more efficiently.  

This information sheet highlights how the check-list was not used properly during one of the three time-outs. Three events occurred in the 1st time-out, “waiting time before anaesthesia” and/or 2nd preoperative time-out "waiting time before surgery”, and a 3rd time-out “waiting time before leaving the theatre” on the CL. It also recalls check-list good practices in the theatre. 

Analysis of the deep-rooted causes and defective barriers shows a failure to communicate, pass on information and poor team work.  

Compliant use of the check-list in the theatre is an effective barrier for impeding such events.