Surgical safety update

A fatal delay in requesting emergency CT

On day zero, a fit, 82-year-old woman attended the emergency department with intermittent abdominal pain for 24 hours. She was known to suffer from constipation and diverticulitis, hypertension, arthritis and had undergone a hysterectomy previously. All blood tests were within normal limits, and she was reviewed by the OPAL team and discharged home. The next day, she reattended the emergency department complaining of severe pain and was referred to the surgical team. She had normal observations, and the initial diagnosis was acute diverticulitis. The surgical registrar contemplated requesting a computed tomography (CT) scan but decided to wait for renal function blood test results before proceeding. It was a very busy day and chasing the results was not prioritised. After a very long delay, the patient left the hospital. She represented the following morning shocked and profoundly unwell with obvious peritonitis. A short section of ischaemic small bowel was found, due to volvulus of the segment of bowel around a dense adhesional band from previous hysterectomy surgery. Unfortunately, the patient died, despite emergency laparotomy and critical care.

Reporter’s comments

This was considered to be a preventable death and was subject to a Prevention of Future Deaths (PFD) notice by HM Coroner. The learning was that, despite a Joint Statement by The Royal College of Radiologists and the Royal College of Emergency Medicine regarding emergency CT scans and the use of intravenous iodinated contrast agent, surgical staff did not know that in the emergency setting the balance of risk of contrast-induced renal dysfunction is highly likely to be offset by the risk of delay in diagnosis and that (as a matter of judgment) abdominal/pelvic CT can be undertaken safely without waiting for renal function results or for prior hydration of the patient. The deficit in knowledge was compounded by an extremely busy emergency service and the surgical middle-grade did not prioritise chasing the blood results, leading to an intolerable delay. Part of the PFD action was to report this incident to CORESS to ensure dissemination of the learning across the profession.

Scan this code to find the joint statement on emergency CT scans and the use of intravenous iodinated contrast agents.

CORESS comments

This case is the subject of a PFD notice issued by HM coroner as it was felt that a timely CT scan would have led to intervention before the patient developed peritonitis. The key learning point is that in the emergency setting (where diagnostic delay could be more detrimental than contrast-induced renal dysfunction), abdominal/pelvic CT can be undertaken safely without waiting for blood test results or for prior hydration of the patient. A joint position statement to this effect was issued in 2023.

It was also noteworthy that a complaint of new symptoms in an elderly patient could be considered a red flag, particularly since one of the features of small bowel ischaemia is a discordance in abdominal signs compared with the symptom of abdominal pain. Both factors may have influenced the decision-making on the day. In such a case, the CT and bloods should be requested simultaneously and a plan made for timely review of the patient.

Total hip replacement – use of non-compatible implants 

A man in his fifties underwent a left hip resurfacing using a system that requires a specific match between the head and cup components. To ensure this, the components are packaged with colour coding. During the procedure, a 50mm ‘GREY’ head was implanted with a 52mm ‘RED’ cup. This component size mismatch and the associated component ‘colour’ discrepancy was not noted at the time of the surgery. The mismatched components led to early failure of the prosthesis. The resurfacing was revised two years later. To compound this error, the additional failure to register the implant with the National Joint Registry meant this additional check was not introduced. Damages of £15,000 plus costs were awarded. 

Messages

Components should be checked by the surgeon and scrub team at the time they are opened and implanted and a final review and check for compatibility should be made prior to closure.

Implant identification data must be submitted to the National Joint Registry. While helpful, the use of colour coding is not fail-safe, particularly if members of the surgical team might be colour-blind.

CORESS comments

It was noted that the devices branch of the Medicines and Healthcare products Regulatory Agency has investigated colour coding of devices extensively. Problems arise because of different colours being recognised internationally, manufacturers changing colours, variation in text sizes and labelling on packaging. Universal barcoding may help to reduce incidents but is not a panacea. 

Risks of device or implant mismatch are reduced by triangulation of colours with numerical component sizes, and by dual verification by more than one member of the surgical team. Prior to starting a procedure, checks should be undertaken to ensure matching components and that all relevant component sizes are available.

Implant verification processes are covered in detail in the National Safety Standards for Invasive Procedures (NatSSIPs 2) from the Centre for Perioperative Care (CPOC)¹. 

Swab count troubles

A 20-year-old woman with a childhood diagnosis of inflammatory bowel disease underwent a difficult re-do laparotomy for adhesive bowel obstruction. As was the surgeon’s usual practice, large swabs were placed around the prepped abdomen under the drapes. The case began in the afternoon but went on into the evening and a change of scrub staff took place mid-way through what was a very long operation with over six hours of surgical time. The swab count began as the surgeon began to close the abdomen but the mismatched count was not noted until the abdomen was closed and the drapes removed, at which time the swabs under the drapes could be counted. The scrub staff had assumed that there were five swabs under the drapes when, in fact, there were only four – which led to the realisation of a swab that was unaccounted for. The abdomen was re-opened and the ‘fifth swab’ retrieved from the left upper quadrant. An apology was given to the patient and they recovered uneventfully.

Reporter’s comments

The swabs placed under the drapes were mentioned during the scrub-team handover but there was nothing written down to document how many had been used. A tired surgical team may have contributed to the events.

CORESS comments 

CORESS noted that it is not usual practice to place swabs from the count under the drapes. This was undoubtedly a factor, since there was no documentation of the swabs on ‘the board’ and there was a change of staff during the procedure. Accountability for reconciliation of the swabs (the swab count) falls to the entire team and not just the surgeon or the scrub practitioner. 

While, on one hand, the reconciliation process did work, the atypical nature of the swab placement was a critical factor. A regular ‘situation report’ during a long case can give the opportunity to update new team members on factors discussed at the briefing or, as in this case, during the case.

The Health Services Safety Investigations Body recently updated its investigation report, which highlights the complexity of the process and makes recommendations in collaboration with CPOC and the Association for Perioperative Practice. 

To read the report, please scan this QR code.

• Published cases will be acknowledged by a Certificate of Contribution, which may be included in the contributor’s record of continuing professional development.
• CORESS is an independent charity, supported by AXA Health.
• We are grateful to those who have provided the material for these reports.
• The online reporting form is on our website, www.coress.org. uk, which also includes previous Feedback Reports.

Reference

1. Centre for Perioperative Care (CPOC). National Safety Standards for Invasive Procedures (NatSSIPs). London: CPOC. https://cpoc.org.uk/guidelines-resources-guidelines/national-safety-standards-invasive-procedures-natssips. Accessed 9 January 2025.