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A clinical "near miss" highlights risk management issues surrounding ultrasound-guided and wire-localised breast resections.

Title: A clinical "near miss" highlights risk management issues surrounding ultrasound-guided and wire-localised breast resections.
Authors: Leff DR
Vincent C
Al-Mufti A
Cunningham D
Darzi A
Hadjiminas D
Item Type: Journal Article
Abstract: 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.
Issue Date: 16-Jul-2012
Date of Acceptance: 16-Jul-2012
URI: http://hdl.handle.net/10044/1/44625
DOI: https://dx.doi.org/10.1186/1754-9493-6-15
ISSN: 1754-9493
Publisher: BioMed Central
Journal / Book Title: Patient Safety in Surgery
Volume: 6
Issue: 1
Copyright Statement: © 2012 Leff et al.; licensee BioMed Central Ltd. 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/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Keywords: 1103 Clinical Sciences
Publication Status: Published
Article Number: 15
Appears in Collections:Department of Surgery and Cancer
Institute of Global Health Innovation