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Surgical procedures are undertaken in many healthcare settings including primary care and radiology. These procedures are undertaken in day surgery units and on an outpatient basis as well as during inpatient care. 


Between 1 April 2007 and 31 March 2008 there were 135,247 incidents reported in surgical specialities to the Reporting and Learning System (RLS).


The National Reporting and Learning Service is working to help healthcare organisations reduce the risks during surgery in a number of ways, including:


  • Establishing the Clinical Board for Surgical Safety in October 2007. The Board is chaired by President of Royal College of Surgeons and membership includes representation from all relevant colleges and associations

  • Working with the World Health Organisation on their Safe Surgery Saves Lives Challenge, launched in June 2008

  • Developing a surgical safety checklist for England and Wales and promoting the Five Steps to Safer Surgery.


Search for guidance on improving patient safety during surgery below.

TitleIssue dateType
Establishing a standard crash call telephone number in hospitals24 February 2004Alert
Improving infusion device safety20 May 2004Alert
Protecting patients who are neck breathers07 March 2005Alert
High dose morphine and diamorphine injections25 May 2006Alert
Right patient, right blood: advice for safer blood transfusions09 November 2006Alert
Right patient, right blood: core competencies09 November 2006Alert
Patient Safety Observatory Report 4: Safety in doses01 January 2007Data report
Actions that can make anticoagulant therapy safer: Work competences01 March 2007Alert
Epidural injections and infusions28 March 2007Alert
Reducing the risk of hyponatraemia when administering intravenous infusions to...28 March 2007Alert
Actions that can make oral anticoagulant therapy safer: Information for...28 March 2007Alert
Actions that can make anticoagulant therapy safer: Alert and other information28 March 2007Alert
Emergency support in surgical units: dealing with haemorrhage10 September 2007Alert
Chest drains: risks associated with the insertion of chest drains01 May 2008Alert
Reducing dosing errors with opioid medicines04 July 2008Alert
Team Self Review08 December 2008Guidance
Avoiding wrong side burr holes-craniotomy11 December 2008Alert
WHO Surgical Safety Checklist26 January 2009Alert
Never Events Framework 2009-1001 February 2009Guidance
Reducing risk of harm from oral bowel cleansing solutions19 February 2009Alert

Checklist evaluation

Surgical Checklist Implementation Project (SCIP)

Imperial College London and Imperial College Healthcare NHS Trust have been awarded an National Institute for Health Research grant to undertake an in-depth national evaluation of the Surgical Safety Checklist in England.

The evaluation with focus on Checklist usability and its contribution to safer care delivery.

More information on the SCIP website

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