Resources Module 10: Patient Safety and Invasive Procedures

Patient Story

Dr. David Ring, a surgeon at Massachusetts General Hospital, had wrapped up his final operation of the day and returned to his office dictate his report. But as he began to record, the enormity of what he had done hit him cold.

For his last operation that day, Ring would see a 65-year-old patient who was admitted to surgery for trigger finger in her left ring finger. The condition describes a finger or thumb that catches in a bent position and then straightens with a snap, much like a trigger.

Ring went through the all the necessary steps -- he verified the symptoms, the abnormal findings on her physical examination and the informed consent. He confirmed the trigger finger was on the patient's left ring finger and reviewed the procedure with her. But then Ring left to perform a carpal tunnel release on another patient.

When he returned, he noticed a switch in the operating staff. Stress ran high among surgeons since several surgeons were behind schedule. Ring's mind was wrapped around the previous carpal tunnel procedure he just performed. The patient's arm had been washed with soap, alcohol, and povidone-iodine. The alcohol had caused the surgery site-marking to wash off. And when Ring spoke to his patient in Spanish moments before the procedure, the circulating nurse didn't understand.

He performed a carpal-tunnel release, removing a band of tissue around the wrist- a common procedure to treat carpal tunnel syndrome. He should have performed a trigger-finger release, which required cutting a tendon in the finger. Realising his mistake moments after leaving the operation theatre, Ring rushed back to the patient, told her the mistake, and performed the necessary procedure.

21% of hand surgeons said they operated on the wrong site at least once in their career, according to a 2003 survey by the American Academy of Orthopedic Surgeons. (NEJM,2010)

Patient Safety and Invasive Procedures

Over 230 million major surgical procedures are carried out worldwide every year. Evidence suggests that in 0.4–0.8% of these cases, patients die as a direct consequence of the surgical procedure. Patients experience complications following 3–16% of surgical procedures. This equates to 1 million deaths and a further 6 million disabilities each year worldwide.

There are many validated tools now available to assist health-care teams in delivering safe surgical care including the WHO Surgical Safety Checklist (WHO, 2023) But a protocol or a checklist is only useful if the people using it trust it and understand why its use leads to better patient care. Protocols can prevent the wrong patient from receiving the wrong treatment, as well as facilitate better communication among team members and the patient.

The causes of adverse events associated with surgical and other invasive procedures include traditional factors leading to adverse outcomes in surgery focused on the skills of the person performing the procedure and the age and physical condition of the patient. Nowadays, many other factors, such as the design of the workplace, teamwork and organizational culture, are thought to have a direct impact on surgical outcomes. Surgical wound infections constitute the second largest category of adverse events and confirm the belief that hospital-based infections (e.g. staphylococcal) constitute a great risk for hospitalized patients, particularly those receiving surgical care. A range of pre-existing conditions (latent factors) have been identified as contributing to adverse events. Latent factors include:  inadequate implementation of protocols or guidelines, poor leadership and poor teamwork, conflict between different departments/groups, inadequate training and preparation of staff, inadequate resources, lack of evidence-based practice, poor work culture, overwork and lack of a system for managing performance. Miscommunication is one of the biggest problems in the operating environment. Types of communication failures associated with doctors include: occasion, content, audience and purpose.

A verification process ensures that the correct procedure is performed on the right patient, right side, site and the right organ. Effective methods exist, such as evidence-based guidelines, protocols or checklists, to support health-care providers achieve safer care. These evidence-based tools are often developed by groups of multidisciplinary experts using the latest evidence. A guideline gives recommendations about a certain topic. A protocol is a set of sequential steps that should be followed in a particular order, enabling the task to be completed. A checklist is used to ensure that certain mandatory items are not forgotten. A WHO global study, carried out in 2007-2008, which looked at the effects of a simple surgical checklist, found that postoperative complications were reduced by more than one third and deaths were halved when the checklist was used. The WHO Surgical Safety Checklist (WHO, 2008) is a practical tool that any surgical team in the world can use to ensure that the preoperative, intraoperative and postoperative steps that have been shown to benefit patients are undertaken in a timely and efficient way. It follows an established framework for safe intraoperative care in hospitals. The aim of the WHO Surgical Safety Checklist is not to prescribe a single approach, but to ensure that key safety elements are incorporated into the operating room routine.

Effective communication and teamwork can help improve patient safety in surgical procedures so will the processes for reviewing mortality and morbidity, for example, many hospitals will have surgical review meetings, (mortality and morbidity meetings). These are forums for discussing incidents and difficult cases and are the main peer-review method for improving future patient care. Such meetings provide a forum for auditing surgical complications or deaths and are necessary for improving practice in a surgical unit.                    


Read more using WHO handout, Patient Safety and Invasive Procedures (WHO, 2012)

Optional reading for this Topic includes:  Wrong Site Surgery (BJO, 2006) and Patient Safety in Surgery - an open access journal by BioMed Central (BMC, 2016)   



BioMed Central (BMC) (2016) Patient Safety in Surgery [Online][Accessed on 1st October 2023][Available at]

British Journal of Ophthalmology (BJO) (2006) Wrong Site surgery [Online][Accessed on 1st October 2023][Available at

New England Journal of Medicine (NEJM)(2010) Case 34-2010. A 65 year old woman with an incorrect operation on the left hand [Online][Accessed on 1st October 2023][Available at

World Health Organization (WHO) (2023) WHO Surgical Safety Checklist and Implementation Manual. World Alliance for Patient Safety [Online][Accessed on 1st October 2023][Available at]

World Health Organization (WHO) (2012).Patient Safety and Invasive Procedures [Online][Accessed on 1st October 2023][Available at]

Last modified: Wednesday, November 15, 2023, 9:38 AM