A serious safety incident involving the use of a contaminated surgical instrument has prompted an investigation by the Healthcare Safety Investigation Branch (HSIB). Among the recommendations of this must-read report is the need for national reporting of safety incidents involving sterile services. Louise Frampton reports.
A report by the Healthcare safety Investigation Branch (HSIB) has identified gaps in the UK healthcare system which could result in patient safety risks associated with contaminated surgical instruments. The HSIB has warned that there is no national picture of the scale of the problem of dirty instruments arriving in operating theatres for use on patients, and is calling for reporting of such incidents, better training and competency assessment, changes to governance, and improvements to the design of surgical instruments.
The HSIB report follows a national investigation prompted by an incident in which ‘black material’ was seen coming out of the end of a surgical instrument. This was later confirmed to be dried blood and, as a result, the patient had to be tested for bloodborne viruses.
The reference case
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