A clinical

Patient Safety in Surgery

Dimitri J Hadjiminas²  Ara Darzi²  Deborah Cunningham¹  Ragheed Al-Mufti²  Charles Vincent³  Daniel Richard Leff² 

[1] Department of Radiology, Imperial College Healthcare NHS Trust, London, United Kingdom;Department of Breast Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom;Centre for Patient Safety and Service Quality (CPSSQ), Department of Bio surgery and Surgical Technology, Imperial College London, London, United Kingdom

关键词: Wire;    Mammography;    Ultrasound;    Cancer;    Breast;   

Others  :  790345
DOI  :  10.1186/1754-9493-6-15

 received in 2012-03-27, accepted in 2012-07-16,  发布年份 2012

【 摘 要 】

Background

The introduction of the National Health Service (NHS) Breast Screening Programme has led to a considerable increase in the detection of impalpable breast cancer. Patients with impalpable breast cancer typically undergo oncological resection facilitated either by the insertion of guide wires placed stereo-tactically or through ultra-sound guided skin markings to delineate the extent of a lesion. The need for radiological interventions on the day of surgery adds complexity and introduces the risk that a patient may accidentally transferred to the operating room directly without the image guidance procedure.

Case report

A case is described of a patient who required a pre-operative ultrasound scan in order to localise an impalpable breast cancer but who was accidentally taken directly to the operating theatre (OR) and anaesthetised without pre-operative intervention. The radiologist was called to the OR and an on-table ultrasound was performed without further consequence.

Conclusion

It is evident that breast cancer patients undergoing image-guided resection are exposed to an additional layer of clinical risks. These risks are not offset by the World Health Organisation surgical safety checklist in its present guise. Here, we review a number of simple and inexpensive changes to the system that may improve the safety of the breast cancer patient undergoing surgery.

【 授权许可】

   
2012 Leff et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

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