Patient Safety Incidents Caused by Poor Quality Surgical Instruments.
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2019-06
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Abstract
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Surgeons require high-quality surgical instruments to carry out successful procedures. Poor quality instruments may break intraoperatively leading to a failed procedure or causing harm to the patient. By examining the National Reporting and Learning Service (NRLS) database, the study aims to define the scale of the problem and provide evidence for the formation of surgical instrument quality control.Methods
The NRLS was searched from August 2004 - December 2010. The search revealed 2036 incidents, 250 of which were randomly selected and analyzed by a clinical reviewer.Results
One hundred and sixty-one incidents were identified causing five reoperations, one incident of severe harm, six incidents of moderate harm, 35 of low harm, and 119 no harm incidents. No patient deaths were discovered. Drillbits were the most commonly broken instrument.Conclusions
This report is likely to only be the tip of the iceberg. Poor reporting of patient safety incidents means that there may be as many as 1500 incidents a year of poor quality surgical instruments causing harm. We suggest that forming a Surgical Instrument Quality Service at Trusts within the National Health Service (NHS) could prevent harm coming to patients, reduce cost, and improve the outcomes of surgical procedures.Type
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Dominguez, Elizabeth D, and Brett Rocos (2019). Patient Safety Incidents Caused by Poor Quality Surgical Instruments. Cureus, 11(6). p. e4877. 10.7759/cureus.4877 Retrieved from https://hdl.handle.net/10161/26493.
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Brett Rocos
I joined the team at Duke University Health from London, UK, where I was a Consultant Adult and Paediatric Spine Surgeon at Barts Health NHS Trust and Honorary Consultant Senior Lecturer at Queen Mary University of London. I completed my surgical training in in the South West of the UK and at the University of Toronto, and am fellowship trained in adult spine surgery, paediatric spine surgery, orthopaedic trauma surgery, research and healthcare management.
I am driven to support patients at every stage of their care, from clinic assessment, through surgery to discharge. Making sure that every person, adult, child, family or friend understands what’s wrong, helping them to choose the right treatment for them, and what the recovery will be like is an important priority.
My research activity focusses on finding effective new treatments for spinal disorders and bringing them to patients. Focusing on spinal deformity, I have led investigations in the UK, Canada and the USA, and I sit on the Global AO Knowledge Forum for Deformity and the Research Grants Committee at the Scoliosis Research Society. I have lectured in North America and Europe about the treatment of spine disorders for the Scoliosis Research Society, Global Spine Congress, AO Spine and Eurospine, and I have worked hard to produce research that improves the care for spine patients wherever they live. Lastly, I review for several orthopaedic journals and I am Deputy Editor of the Bone and Joint 360, a leading publication with a global readership.
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