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Surgical instruments left in patients and other errors
posted: Thursday January 15th, 2009

Remember the Herald of Free Enterprise?
In 1987, one hundred and ninety-three passengers and crew died because a modern car-ferry set sail from Zeebrugge with the bow doors open and sank within 3 minutes of leaving harbour.
'How could this happen?' was the immediate and universal reaction - why did the captain not notice that the bow-door indicator light was not on?
The quite astonishing answer is that there was no warning light on the bridge, or any other fail-safe system in place to physically prevent it happening. As is so often the case in a major disaster, a series of omissions, sloppy procedures and human errors led the captain to leave port believing that the bow doors were closed. His assumption was incorrect and a major disaster ensued.

Patient deaths during or after surgery can also be caused by human error - it is regrettable but it happens - no one is perfect nor is it reasonable to expect them to be.

Today I read, surprise surprise, that using a simple surgical checklist during major operations can cut deaths by more than 40% and complications by more than a third. This checklist is so basic (view it here) that one has to ask why a similar procedure is not standard practice within the NHS. To be fair, many hospitals probably do have excellent systems in place, but why is a mandatory, simple and constantly evolving system not in place across the entire NHS?

Can we assume that NHS managers have never heard about patients having the wrong leg or kidney removed or having swabs or instruments left inside them?

Are these people so stupid that they have not thought of such a simple checklist themselves - even if only to cover their own backs in the time-honoured tradition of NHS management?

Evidently they are.

I am certainly not the only one utterly horrified to discover that a mandatory system is not already in place; no warning light on the bridge; and no universal checklist to ensure we amputate the correct limb.

But even worse is the reaction of the National Patient Safety Agency (NPSA) to this research. Let's ignore the fact that it has allowed the present unregulated situation to become the status quo, it compounds its breath-taking negligence by ordering all hospitals in England and Wales to use this checklist across the board by February 2010.

That's right, an entire year to introduce a simple checklist whilst more patients continue to die unnecessarily from human error!

Such a system could and should be in place in weeks, if not days.

That senior NPSA management can even consider a delay of a year is a very clear indication that, just like senior NHS management in general, they live on another planet from the rest of us, are unaccountable, totally incompetent, lack basic common sense, and don't give a damn about patients.


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