Course taster

Anaesthetic and Surgical Mortality

In 2006, the tragic death of Tony Clowes of Dagenham, UK, was one of the unfortunate cases raising healthcare staff awareness of safer surgery and anaesthesia. Tony, a nine-year-old boy who had accidently caught his finger in his bicycle chain, attended Essex Hospital for a routine operation. A system neglect error occurred where a plastic cap blocked the oxygen tube used in general anaesthesia. The patient died from oxygen starvation. Read NHS trust fined over boy's death (British Broadcasting Corporation 2006) and more: How could someone end my little boy's life?

During this decade, other incidents occurred in hospital operating departments, and Essex Police were asked to participate in addressing the Operation Orcadian NHS Incidents. The UK Department of Health (2007) published its Protecting the breathing circuit in anaesthesia report in May 2004. This report details what had occurred in numerous operating department incidents and the actions required, ensuring patient safety is paramount.

Practise your literature search techniques by navigating to the Royal College of Anaesthetists (RCoA) website, also known as Anaesthesia UK, and searching for "Protecting the breathing circuit in anaesthesia". You will be presented with a copy of the report to the chief medical officer of an expert group on blocked anaesthetic tubing. The report is also linked to from the UK National Archives

A decade later, many ask: has surgery become safer? According to the British Medical Journal (Campbell 2013), the mortality rate or risk of death for surgical patients is 82% higher at weekends than on a Monday. There were 4.1 million elective surgeries carried out in hospitals between 2008 and 2011, with a rate of 27,582 patients dying within 30 days of surgery. Read more (Campbell 2013): Risk of death from surgery greater at the weekend, study finds

Hospital errors still occur today, although not all are within the perioperative environment. Nevertheless, understanding what happened supports theatre staff in reducing the risks in their environment. The Times reported on Saturday 14th January 2017 that "Hospital errors led to death of surgeon's father" (Paige 2017). Unfortunately, a medical error caused the patient, Robert Welch (93 years of age), to die after being mistakenly injected with insulin instead of dextrose. Mr Andrew Welch (a surgeon and Robert’s son) commented: "I am quite confident that [the trust] had grasped the nettle. They have reacted quickly. I am comfortable with what they have done. My main aim was to make sure it does not happen again." Read more: Hospital error led to death of surgeon's father

Activity 1.2

The discussion board activity in this unit is to consider how you and your place of work promote safer surgery. Activity 1.2 asks you to think about your setting and to highlight the activities you undertake to ensure the patient undergoes the correct procedure. You might consider the language you adopt with the patient during the WHO surgical checklist or where standardised documentation minimises human errors. Remember to include your country location at the bottom of your posting so that we can build up an international picture of perioperative practice (The link to the Discussion Board is not available in this course taster).

Please continue to consider perioperative care and safer surgery in your practice because in a while we will be meeting our four virtual patients, who will discuss their presenting complaints.