While adverse events in the OR are infrequent, complex surgery still carries risks of preventable errors that can gravely impact patient health. We review the most frequent oversights and the robust safety barriers hospitals implement across the entire perioperative continuum to protect patients.
Wrong Site Surgery
Operating on the wrong body part – often getting the right and left side confused – tops the list of flubs. Robust preoperative verification processes aim to prevent such wrong site errors. Surgeons initial the correct anatomical site with the patient awake and aware before anesthesia. Site markings must be unambiguous and visible after draping. Checklists, pauses and time outs coordinate care teams to actively confirm laterality consensus including nursing staff and techs.
Retained Foreign Objects
Surgical instruments, sponges, electrosurgery pads or accessory items left inside a patient’s body cavity trigger extreme consequences. Methodical wound counts ensure retrieval removal of all materials before closure aided by meticulous documentation. Some facilities attach barcoded tags to sponges detectable by X-ray when lost intrasurgically. If retention issues arise postoperatively, imaging helps detect oversight items.
Inadequate administration, insufficient monitoring or medication overdoses during surgery or sedation frequently cause nerve damage, organ failure and even death. Standardized machine checkout protocols, drug labeling requirements and independent double verification processes help avoid drug mix-ups or dosing miscalculations. Care teams religiously document patient weight along with health histories noting allergies preoperatively preventing miscues. Continuous pulse oximetry and capnography monitoring respiration status makes respiration depression more apparent.
Surgical fires occur when heat generating tools like electrosurgical units ignite alcohol prep solution or enriched oxygen environments. Meticulous skin preparation technique allows full drying before draping. No alcohol-based skin solution may be used under surgical drapes. Clinicians minimize the use of supplemental oxygen avoiding enrichment without necessity. Comprehensive fire risk assessments should happen for every procedure type enabling ready response plans.
Total power outages, malfunctioning instruments or faulty alarm systems during intensive surgery can have devastating impacts on patient stability. Robust preventative maintenance protocols ensure peak performance while intraoperative equipment redundancy including backup battery systems allows seamless intervention for electricity, oxygen, suction needs in case of primary failure. Real-time alert systems trigger biomedical support for device errors long before clinical impact.
Incorrect drugs, inaccurate doses, mistimed delivery or improper intravenous infusion rates frequently arising perioperatively can lead to morbidity. Barcode scanning during medication administration verifies drug identity, strength and expiration catching variances between ordered and delivered content. Closed-loop anesthesia delivery devices and IV medication management systems help synchronize instructions with actual administration tamper-proofing the process. Independent double checks by another licensed clinician validate right drug, dose, route and timing before high-risk administrations.
Caused by overburdened staff racing between cases, critical treatments, specimens or testing occasionally get wrongly ordered or administered to the incorrect patient. Mandating at least two patient identifiers gets confirmed verbally and by wristband check before all interventions. Photos embedded in electronic records act as an additional visual confirmation guarding against mismatches especially helpful before anesthesia or blood transfusion events.
Pathogen transmission through contaminated instrumentation, devices or unhygienic operating room environments frequently causes dangerous surgical site infections. Strict sterile protocols guide OR sanitization, equipment handling and team entry processes. Surgical safety checklists ensure instrument sterility monitoring, facility ventilation and minimal traffic. Screening patients preoperatively for nasal colonization or other infection risks prompts preventative antibiotic dosing when warranted.
Protecting patients involves accepting human fallibility in complex systems and engineering consistent safety barriers at every junction from preoperative time-outs to intraoperative monitors that dramatically minimize the opportunity for errors to translate into real harm.