Accidentally falling instruments during orthopaedic surgery: Time to wake up!

作者:Khan Shah A*; Kumar Ashok; Varshney Manish K; Trikha Vivek; Yadav Chandershekar
来源:ANZ Journal of Surgery, 2008, 78(9): 794-795.
DOI:10.1111/j.1445-2197.2008.04652.x

摘要

Background: The aim of the study was to evaluate statistically the Occurrence and causes of accidental fall of instruments and implants during orthopaedic procedures. Methods: A prospective study was carried out over a period of 18 months. Total of 120 randomly chosen major orthopaedic surgeries were observed. The observer counted the number of times an instrument fell during surgery. The offending operating room personnel were identified. A note of the nature of instrument falling was made. Results: A total of 120 surgeries were observed. There were 15 falls (38.5%) during elective surgeries and 24 (61.5%) during emergency (trauma) surgeries. Falls were classified as major and minor. There were a total of 39 falls with I I major and 28 minor falls. Seven surgeries had two or more falls. In 26 instances (66.7%) the operating surgeon was responsible for the fall. In seven (17.9%) assisting surgeon and in three (7.7%) of the instances the scrub nurse was responsible for the fall of the instruments. Three falls (7.7%) were unaccountable. An average delay of 7.6 min was noted after the fall of the instrument or implant. Conclusions: Fall of instruments in the theatre is a common problem all over the world. It leads to increased operating time and extra resources and can hamper the end result of surgery. Our study is the first of its kind to evaluate the problem. Most falls occurred because of the operating surgeon. A course in instrument handling similar to one conducted by the theatre nurses may be helpful in preventing such falls.