Surgical Safety

Even though surgical procedures are intended to save lives, unsafe surgical care can cause substantial harm to patients (WHO Safe Surgery programme).

In developed countries, nearly half of all adverse events in hospitalised patients are related to surgical care, and at least half of the cases in which surgery led to harm could be considered preventable.

In this article, we describe the surgical safety checks and protocols that should take place to reduce the risk of such preventable errors.

Note: Many of these checks may not be feasible in emergency surgery. Checks should be completed if they do not cause the patient any harm.


Ward Checklist

A ward checklist should be completed prior to a patient’s operation. It provides initial checks for both operating staff and the ward nursing staff:

  • Surgical check – requires the operating surgeon or a nominated deputy (who should be present in operating theatre throughout) to meet the patient on the ward prior to the operation.
    • The surgical check should confirm the patient identify, the intended operation, and site of the operation with the patient, with the site of operation marked.
  • Fig. 1 - Example Nursing Checklist

    Fig. 1 – Example Nursing Checklist for Pre-Operative Management

    Nursing check – completed by a member of the nursing staff involved in the patient’s pre- and post-operative care. All consent forms should be checked, infection risk assessed, appropriate VTE prophylaxis prescribed and given, and baseline observations recorded.

Pre-Operative Surgical Site Marking

The pre-operative marking of a patient has a significant role in surgical safety, and can prevent wrong-site surgery.

Surgical marking should ideally be made by the operating surgeon, as part of the surgical check in the ward checklist. The site must be re-confirmed during the intra-operative ‘Time Out’ checks.

The correct site for surgery must be confirmed by checking against the patient’s records, consent form, operating list and, when possible, verbally with the patient (or appropriate family members).

An appropriate skin marker pen must be used and the mark must be an arrow that extends to near the incision site and should remain visible after the application of theatre drapes.

Note: Ensure the mark does not extend onto the intended incision site, as this can result in the permanent ‘tattooing’ of the patient due to the involvement of the ink with the surgical incision.

When performing laparoscopic surgery, the side of the structure being treated must be indicated by a pre-operative mark on the skin, in proximity to the structure being operated on. For digits on the hand and foot, the mark must extend to identify the correct specific digit.

Circumstances where site marking may not be appropriate include:

  • Emergency surgery
  • Operative procedures on teeth and mucous membranes
  • Cases of bilateral simultaneous organ surgery
  • Situations where the side of pathology needs to be confirmed following examination under anaesthesia

Theatre Checklist

The WHO surgical checklist is an essential part of surgical safety. The use of the checklist has been shown to reduce the rate of major post-operative complications from 11% to 7% and mortality rate following major operations from 1.5% to 0.8%.

The checklist must be completed for all surgical interventions, ranging from general anaesthetic operations to local anaesthetic interventions. A registered theatre practitioner should take the lead in completing the document.

A copy of the completed checklist must be retained in the patient’s notes or electronic clinical record.

WHO Surgical Safety Checklist

The WHO Surgical Safety Checklist (Fig. 2) is divided into three sections, to be completed at three separate times during the operative period:

  • Sign In – To be completed before the induction of anaesthesia, in the presence of the anaesthetist.
  • Time Out – To be completed before the first incision, acting as the final opportunity to identify the patient, the procedure, and the site involved.
  • Sign Out – To be completed prior to the key members of the operating team leaving the operating room.
Fig 1 - The WHO checklist. If attending theatre, make sure you are counted in.

Fig 2 – The WHO surgical safety checklist


Infection Control

Ensuring a sterile surgical environment is an essential part of surgical safety. The key areas of surgical infection control include:

  • Sterility of all surgical equipment
  • Effective scrubbing-up technique (found here)
  • Empirical prophylactic antibiotics (as below)
  • Adherence to intra-operative infection control measures (found here)

Surgical Antibiotic Prophylaxis

Prophylactic antibiotics are given to counter a high risk of wound infection, or in regions where infection causes severe consequences (such as a prosthesis).

In the UK, NICE guidance recommends antibiotic prophylaxis should be given to patients before:

  • Clean surgery involving a prosthesis or implant
  • Clean-contaminated surgery
  • Contaminated surgery

Antibiotics are typically given as a single dose IV (extra doses may be needed in prolonged surgery or excessive blood loss), within 60mins before the first incision. Examples of prophylactic intra-operative antibiotics are given in Table 1.

Any patient identified with MRSA should receive appropriate antibiotic treatment, e.g. IV Teicoplanin or intranasal mupirocin.

Operation Type Prophylactic Antibiotic
Gastrointestinal and HPB
  • Open GI surgery without sepsis = Gentamycin IV + Metronidazole 500g IV (n.b. Appendicitis = Metronidazole 500g IV only)
  • Intra-abdominal sepsis (inc. HPB) = Piperacillin-Tazobactam 4.5g TDS IV & Gentamicin IV
  • Laparoscopic surgery = Co-Amoxiclav 1.2g IV
Vascular
  • Majority of vascular procedures = Flucloxacillin 1g IV
Urology
  • Open urological surgery inc. bowel or vagina = Amoxicillin 1g IV + Gentamycin IV + Metronidazole 500mg IV
  • Prostatic biopsy = Co-Amoxiclav 625mg PO
Orthopaedics
  • Joint replacement = Flucloxacillin 1g IV + Gentamycin IV
  • Open fractures = Co-amoxiclav 1.2g IV + Gentamycin IV + Metonidazole 500mg IV

Impregnated cement is recommended for cemented joint replacements. Up to 24hrs antibiotic prophylaxis should be considered for arthroplasty,

Table 1 – Example Surgical Antibiotic Prophylaxis

Further Reading

WHO Guidelines for Safe Surgery: Safe Surgery Saves Lives
WHO

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