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Avoiding wrong side burr holes-craniotomy

Reference number
1067
Central Alert System (CAS) reference
NPSA/2008/RRR009
Issue date11 December 2008
Action date (if applicable) (date field)12 May 2009
DH Gateway reference
10848
TypeAlert

This Rapid Response Report alerts healthcare organisations to the risks of wrong side surgery when drilling burr holes during neurosurgery in both adults and children.


The National Reporting and Learning Service (NRLS) received reports of 15 incidents of patients receiving surgery on the wrong side of the head (through wrong-side burr holes or craniotomies) between January 2005 and September 2008. 


Common themes included:


  • a failure to state side of surgery on operating list and consent form;
  • a failure to mark side of surgery;
  • a lack of robust checking procedures pre-operatively; and
  • a lack of challenge by theatre staff when they noticed surgery starting on wrong side.

 

The NRLS recommends that local organisations should review current policy and practice for neurosurgery in both adults and children.


To reduce risks of wrong site surgery, the side of intended surgery should be marked
on the side of the forehead or the back of the neck (below the hairline) for posterior approaches.


This should be done by the operating surgeon on the ward, with imaging, notes and patient consent available. Wherever possible, the patient/carer should be involved in discussion to confirm the operative side.

 


The operating surgeon (or designated member of team) takes ultimate responsibility for ensuring surgery on the correct side. This person should sign checks confirming the correct patient, proposed procedure and the correct side with reference to imaging, clinical records, consent form and operating list.

Although the deadline for actions has passed, this guidance remains best practice. It should be followed to help prevent future patient safety incidents.
Burr holes craniotomy - Rapid Response Report
Burr holes craniotomy - Rapid Response Report - 56 KB 1067 - Burr holes craniotomy - Rapid Response Report - 2008-12-11 -V1
Burr holes craniotomy - Rapid Response Report supporting information
Burr holes craniotomy - Rapid Response Report supporting information - 125 KB 1067A - Burr holes craniotomy - Rapid Response Report supporting information - 2008-12-11 -V1