Following the death of a patient during routine laparoscopic surgery, the National Patient Safety Agency (NPSA) is warning that surgery should not be performed in facilities which lack the systems and equipment to manage emergencies safely. The NPSA said the incident was exacerbated by the fact that no blood was available.
There was a lack of critical resuscitation devices and an absence of surgical equipment such as abdominal packs and vascular sutures. In addition, the agency said that poor communication, lack of back-up surgical assistance and a lack of basic communication devices (including a telephone in the theatre) made the situation worse.
Dr Kevin Cleary, Medical Director at the National Patient Safety Agency said: “Routine elective surgery including laparoscopic surgery has serious but well recognised risks such as severe haemorrhage. All units need to have robust co-ordinated systems in place and equipment which can respond immediately to these emergencies.
The NPSA is advising the NHS and the independent sector that:
· A co-ordinated system for the urgent supply of blood products must be established and maintained.
· Blood must be available quickly for all operations, including the ability to communicate directly and immediately with the transfusion laboratory and for blood products to be transported between the laboratory and the unit without delay.
· All units must have access to emergency equipment that may be required to deal with a haemorrhage, such as the appropriate sutures and packs. This emergency surgical and resuscitation equipment will need to reflect the range of surgery undertaken in the unit and the distance from other healthcare services.
· A formal check should be carried out before every procedure.
· A formal backup system for surgeons and anaesthetists is essential so that consultants have a system for summoning help in emergency situations.
