Table 9 Examples of reported perioperative incidents in HIMS
Examples of reported perioperative incidents in HIMS | |||||
|---|---|---|---|---|---|
HIMS risk classification | Description | Event type | Incident type | Function of reporter | Reported cause |
Low risk | Two patients did not have correct marking signs although the surgeon had signed the checklist. | Adverse event | Communication | Recovery nurse at the holding of the OR | SOP not followed |
Medium risk | During surgery the following happened: | Adverse event | Other | Anesthetic nurse | - Other organization-related problem, namely: “delay because of shortage of staff”; |
- 30 minutes waiting because the patient arrived too late in the OR; | |||||
- For this operation there was no blood typing performed; | - Human error or forgotten. | ||||
- During the time out it appeared that the right size implant was not available. | |||||
High risk | Surgery was performed without recent available imaging. During surgery, it appeared that metastases were increased in size necessitating adjustment of the surgical procedure. | Adverse event | Diagnostics | Radiologist | - SOP not known |
- SOP not available/incomplete/unclear | |||||
- Incorrect performance | |||||
Extreme risk | The headrest of the surgical table suddenly went loose, which could have caused the head of the patient to bend downwards uncontrollably but the head of the patient was stabilized in time by the anesthesiologist. | ‘Near-miss’ event | Equipment | OR nurse | - Broken material; |
- Wrong design; | |||||
- Other human error, namely: “part of the table not correctly fixated”. | |||||