Volume 1 Supplement 1

Safety in Health

Open Access

Leak in Surgical Safety Checklist?

  • Franz J Fellacher1,
  • Doris Walter2,
  • Daniel Aldrian2,
  • Franz J Seibert1 and
  • Renate Krassnig1Email author
Safety in Health20151(Suppl 1):A18

DOI: 10.1186/2056-5917-1-S1-A18

Published: 30 October 2015

Background

Since the dawn of surgery patient safety has been a major issue. In 2008 the WHO Surgical Safety Checklist was developed after extensive consultation, aiming to decrease errors and adverse effects. The WHO Checklist is used originally or based on by a majority of surgical providers around the world - even with us. Nevertheless, mistakes happen.

Material and methods

We report a case that has taken place in our department, supplemented by literature review.

Modified WHO Safety Checklist has been used in our department since a couple of years ago. Although "Team Time Out" was performed standardly following unpleasant situation happened: after an elective arthroscopy, while the surgeon finished documentation, the responsible nurse informed him that the indicator strip for sterility did not show any discoloration.

No one of the operating room personal knew whether the indicator strip was not checked or if it had been overlooked although a modified WHO Surgical Safety Checklist was performed carefully.

Subsequently the question arose, what does it mean to the patient if surgical instruments were not sterilized but only cleaned by Washer-Disinfector.

Results

The patient has not suffered any infection. Review of the literature has shown that the machine washer-disinfector consistently reduces microorganisms [1]. The risk of transmission of infection may be considered negligible [2].
Figure 1

Indicator strip for sterility (black=sterility is given; white=sterility not given).

Conclusion

Despite the use of checklists, errors still happen. Everyone on the team is required not only to do their own part. Moreover, everyone is required to take care of "the whole big picture".

Declarations

Authors’ Affiliations

(1)
Department of Trauma Surgery, Medical University of Graz
(2)
Department of General Surgery, University Hospital Graz

References

  1. Donskey C, Yowler M, Falck-Ytter Y, Kundrapu S, Saltata RA, Rutala WA: A case study of a real-time evaluation of the risk of disease transmission associated with a failure to follow recommended sterilization procedures. Antimicrob Resist Infect Control. 2014, 3 (1): 4-PubMedPubMed CentralView ArticleGoogle Scholar
  2. Rutala WA, Weber DJ: How to assess risk of disease transmission to patients when there is a failure to follow recommended disinfection and sterilization guidelines. Infect Control Hosp Epidemiol. 2007, 28 (2): 146-155.PubMedView ArticleGoogle Scholar

Copyright

© Fellacher et al. 2015

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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