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Reusing surgical instruments during Mohs micrographic surgery: safe from infection, but not free from risk
Tatyana A Petukhova, Thomas H King, Kenny J Omlin
1Department of Dermatology, University of California, Davis, Sacramento, CA. dbeisen@ucdavis.edu.
Abstract:
We report several scenarios of compromise in patient safety owing to the re-use of mis-assigned patient's surgical instruments in Mohs micrographic surgery.We discuss the breaks in universal protocols that others may experience in their practices and describe corrective measures that our institutions employed to avoid such future events.There is a lack of publication in the literature on the topic of mis-assigned instrument use in Mohs surgery. We believe that the practice of re-using instruments is cost-effective and therefore common. Based on our humbling experience, this publication may initiate important discussion among dermatologist regarding safety protocols at their respective institutions.
Insights
Mis-assigned surgical instruments reused in Mohs surgery compromise patient safety. This highlights critical breaks in universal protocols, necessitating improved safety measures in dermatologic surgery practices.
Area of Science:
- Dermatology
- Surgical Safety
- Medical Device Management
Background:
- Patient safety is paramount in surgical procedures.
- Mohs micrographic surgery requires meticulous instrument handling.
- Re-use of surgical instruments, while cost-effective, poses potential risks if mis-assigned.
Purpose of the Study:
- To report scenarios where mis-assigned surgical instrument re-use compromised patient safety in Mohs surgery.
- To identify breaks in universal protocols related to instrument handling.
- To propose corrective measures to prevent future safety compromises.
Main Methods:
- Retrospective review of patient safety incidents.
- Analysis of protocol adherence and instrument management.
- Description of institutional corrective actions implemented.
Main Results:
- Several instances of compromised patient safety due to re-used, mis-assigned instruments in Mohs surgery were identified.
- Breaches in universal protocols were observed.
- Specific corrective measures were developed and implemented.
Conclusions:
- The re-use of mis-assigned surgical instruments presents a significant patient safety risk in Mohs surgery.
- Institutions must review and reinforce universal protocols for instrument handling and assignment.
- Proactive implementation of corrective measures is crucial to prevent such adverse events and enhance surgical safety.
