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
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.