Background:
The introduction of the National Health Service (NHS) Breast Screening Programme has led to a
considerable increase in the detection of impalpable breast cancer. Patients with impalpable breast cancer typically
undergo oncological resection facilitated either by the insertion of guide wires placed stereo-tactically or through
ultra-sound guided skin markings to delineate the extent of a lesion. The need for radiological interventions on the
day of surgery adds complexity and introduces the risk that a patient may accidentally transferred to the operating
room directly without the image guidance procedure.
Case report:
A case is described of a patient who required a pre-operative ultrasound scan in order to localise an
impalpable breast cancer but who was accidentally taken directly to the operating theatre (OR) and anaesthetised
without pre-operative intervention. The radiologist was called to the OR and an on-table ultrasound was performed
without further consequence.
Conclusion:
It is evident that breast cancer patients undergoing image-guided resection are exposed to an
additional layer of clinical risks. These risks are not offset by the World Health Organisation surgical safety checklist
in its present guise. Here, we review a number of simple and inexpensive changes to the system that may improve
the safety of the breast cancer patient undergoing surgery.