Patient Safety Incidents Caused by Poor Quality Surgical Instruments

Abstract

Objectives: 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.

Development of a "Scissor-Tip-Separator" for adjustment of scissor blade separation and prevention of scissor blade damage during steam sterilization

“…In addition, the scrub nurses could quickly inspect and check the scissors' performance during surgical setup. Damage at the point of use renders instruments unusable, resulting in surgical delays that negatively impact patient safety and increase staff workload by requiring the preparation of new instruments [ 16 , 19 ]. Poor quality control of surgical instruments leads to low-quality instruments [ 19 ].…”

“…Damage at the point of use renders instruments unusable, resulting in surgical delays that negatively impact patient safety and increase staff workload by requiring the preparation of new instruments [ 16 , 19 ]. Poor quality control of surgical instruments leads to low-quality instruments [ 19 ]. Any general increase in operating room costs has substantial socio-economic impacts nationwide [ 18 ].…”

“…Therefore, this solution may not meet the standard requirements for steam sterilization of surgical instruments, particularly during the COVID-19 pandemic. In addition, low-quality instruments can disrupt surgical procedures, causing delays in surgery and reduced patient safety [ 18 , 19 ].…”

A Human Factors Approach to Vaginal Retained Foreign Objects

“…Another contributor to RFOs in our institution was issues with the design or use of various tools/technology in surgery (e.g., instrument tip breaking off). A recent study [20] exploring unretrieved device fragments (UDFs) argues that poor-quality control of surgical instruments can lead to the use of instruments that are likely to fail and break. Although difficult to control in surgery, challenges associated with tools and technology can be studied in simulation.…”

Life cycle assessment and life cycle cost of repairing surgical scissors

“…Maintenance and repair are especially important for items such as surgical instruments because intra-operative failure or instrument breakage impacts on the safety of care. Poor quality instruments have been associated with patient safety incidents (Dominguez and Rocos 2019), whilst repair of instruments was associated with reduced rates of surgical site infections in caesarean sections (Stutler et al 2013).…”