Before reading further, and if you have a broadband connection and 15 minutes to spare, you might like to visit: "Just a routine operation" (15 minute video concerning a single case) A transcript of an expert report on the incident is available at: Report (from "Clinical Human Factors Group")

Patient safety has, quite correctly, become a health policy priority around the world

  • In the UK, adverse events cost the National Health Service an estimated £2 billion a year in additional hospital stay alone, without taking into account the human or wider economic costs. A significant proportion of adverse events are associated with a surgical procedure and a third of the referrals from NHS hospitals and community trusts to the National Clinical Assessment Authority, an advisory body on doctors' performance are about surgeons.
  • In every hospital, during the simplest operation or the most complicated, all members of the surgical team should understand their roles within the organizational structure.
  • The role of each member of the team should be clarified in order to achieve a safe environment for the care of the patient. All in theatre-doctors, nurses, technicians, students and ancillaries team are important team members.
  • Human factors research has highlighted a wide range of factors which have the potential to predispose to error. These include poor communication, fatigue and cognitive error.
  • Data from the Australian Incident Monitoring Study, based upon 2000 anaesthetic incidents, identified the following as the 12 most commonly occurring contributing factors. These are not applicable solely to anaesthesia - the same factors affect surgical error.
  1. Misjudgement (16%)
  2. Failure to check equipment (13%)
  3. Fault of technique (13%)
  4. Other human factors problems (13%)
  5. Other equipment problem (13%)
  6. Inattention (12%)
  7. Haste (12%)
  8. Inexperience (11%)
  9. Communication problem (9%)
  10. Inadequate preoperative assessment (7%)
  11. Monitor problem (6%)
  12. Inadequate preoperative preparation (4%)


Many measures have been taken over the years to reduce preventable adverse events. The World Health Organisation (WHO) has put forward a High 5s initiative towards action on patient safety using evidence-based protocols to protect patients from preventable tragedies. These include:


  • Prevention of patient care hand-over errors
  • Prevention of wrong site/wrong procedure/wrong person surgical errors
  • Prevention of continuity of medication errors
  • Prevention of high concentration drug errors
  • Promotion of effective hand hygiene practices


Goals and objectives to prevent these errors were identified as the following:

  • Provide a practical framework to identify defects
  • Identify patient hazards
  • Investigate an adverse event
  • Understand incident reporting
  • Understand the impact of teamwork and communication in safety
  • Acquire skills to improve teamwork and communication through education and patient safety training
  • Learn to disclose medical mistakes with no blame culture
  • Surgical safety checklist

A Surgical safety checklist has been developed to prevent human errors in the operation theatre. With some minor changes, most operation theatres now have these checklists which can be seen by clicking here.


  • Complex systems like healthcare are prone to error and patient harm.

  • We have much to learn from other industries on a true 'safety culture'.

  • Surgical Checklists are but one of many interventions that can improve safety for our patients.

  • Implementing simple interventions can be very effective.

Further reading: