A Retrospective Review of Serious Surgical Incidents in 5 Large UK Teaching Hospitals: A System-Based Approach

Surgical incidents are the most common serious patient safety incidents worldwide. We conducted a review of serious surgical incidents recorded in 5 large teaching hospitals located in one London NHS trust to identify possible contributing factors and propose recommendations for safer healthcare systems.

We searched the Datix system for all serious surgical incidents that occurred in any operating room, excluding critical care departments, and were recorded between October 2014 and December 2016. We used the London Protocol system analysis framework, which involved a 2-stage approach. A brief description of each incident was produced, and an expert panel analyzed these incidents to identify the most likely contributing factors and what changes should be recommended.

One thousand fifty-one surgical incidents were recorded, 14 of which were categorized as "serious" with contributing factors relating to task, equipment and resources, teamwork, work environmental, and organizational and management. Operating room protocols were found to be unavailable, outdated, or not followed correctly in 8 incidents studied. The World Health Organization surgical safety checklist was not adhered to in 8 incidents, with the surgical and anesthetic team not informed about faulty equipment or product shortages before surgery. The lack of effective communication within multidisciplinary teams and inadequate medical staffing levels were perceived to have contributed.

Multiple factors contributed to the occurrence of serious surgical incidents, many of which related to human failures and faulty equipment. The use of faulty equipment needs to be recognized as a major risk within departments and promptly addressed.