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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
Harm from flushing of nasogastric tubes before confirmation of placement22 March 2012Alert
Recognising and instigating prompt treatment for necrotising fasciitis | Signal28 February 2012Signal
Prevention of Harm with Buccal Midazolam | Signal28 February 2012Signal
Risk of skin-prep related fire in operating theatres | Signal28 February 2012Signal
Risk of harm following gastric bypass | Signal28 February 2012Signal
Diagnosis of death after cessation of cardiopulmonary resuscitation | Signal28 February 2012Signal
Risk of harm from CPM syndrome following rapid correction of sodium | Signal28 February 2012Signal
Patient safety issues related to gastrostomy | Signal28 February 2012Signal
Minimising Risks of Mismatching Spinal, Epidural and Regional Devices with...28 November 2011Alert
Early detection and treatment of acute limb ischaemia | Signal25 March 2011Signal
Outbreak of prosthetic valve endocarditis | Signal25 March 2011Signal
Airway suction equipment | Signal14 February 2011Signal
Safer spinal (intrathecal), epidural and regional devices31 January 2011Alert
How to guide to the five steps to safer surgery20 December 2010Guidance
WHO surgical safety checklist: for maternity cases only11 November 2010Guidance
Accurate patient weight | Signal29 October 2010Signal
Haemorrhage following removal of femoral catheters | Signal29 October 2010Signal
Wrong site nerve block | Signal29 October 2010Signal
The transfusion of blood and blood components in an emergency 21 October 2010Alert
Never Events Annual Report 2009/1008 October 2010Data report

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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