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Patient Safety Alert: Equipment Failure During Surgery and Replacement Parts

Several reports in the CHPSO database have pointed to the inaccessibility of spare surgical parts or tools while a procedure is in progress. In several cases, unique screwdrivers or drill bits have broken, or unique-size screws went missing. In at least one instance, the incision had to be temporarily closed with an implant partially secured and the patient was scheduled for re-operation to complete the procedure another day.

These items may only be available through the device manufacturer and not easily replaced. Is your facility prepared to determine what to do in such an instance? Which mechanisms does your facility have in place when you lack critical supplies or a device such as a failed surgical robot?

“Resilience” is the capability to adaptively avert failures and rapidly respond to those that occur. Hospitals already have experience in developing resilience in specific areas, such as disaster response, but most organizations are not yet systematically applying resilience techniques to all applicable areas.

Part of building resilience into a system is preparing in advance for problems, changes and hazards. With surgical equipment, this can be as simple as identifying which pieces of equipment are critical to successfully completing a procedure, then identifying how the organization will cope with failure of that equipment. This could be done when considering the purchase of a new system. If the system under consideration has unique and critical parts, either select a different system with fewer unique parts, or develop a “plan B” for failure, such as redundancy (e.g., a second screwdriver) or a suitable substitute. Then, when failure happens, the organization will be much more likely to successfully recover from failure. While it is not feasible to determine every possible device error, reasonable pre-planning moves an organization closer to achieving high reliability.

Resources:

Courdier S, Garbin O, Hummel M, et al. Equipment failure: causes and consequences in endoscopic gynecologic surgery. J. Minim. Invasive Gynecol. 2009;16(1):28-33. http://www.ncbi.nlm.nih.gov/pubmed/19004670

Kaya AH, Dagcinar A, Celik F, Senel A. Simple technique for removing broken pedicular screw with plain and serviceable screwdriver. Eur. Spine J. 2008;17(8):1116-8. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2518777/

Lekka C. High Reliability Organisations: A Review of the Literature. London; 2011. http://www.hse.gov.uk/research/rrpdf/rr899.pdf

Doctor sued for inserting screwdriver into patient’s back. ABC News, 2006. http://abcnews.go.com/GMA/story?id=1630844

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