Medical device issues cause quarter of operating room errors
26 July 2013
Around a quarter of all operating room errors are caused by
technology or equipment problems, according to an analysis published
online in the journal BMJ Quality & Safety.
Inability to use the technology/equipment, lack of availability,
and faulty devices/machines made up the bulk of the problems, the
The researchers methodically searched for published studies on
errors and problems arising in operating rooms in electronic
databases. After applying a quality assessment technique, they found
28 studies out of a total of 19,362 pieces of research that were
suitable for inclusion in the analysis.
Technology/equipment issues cropped up in an average of 15.5% of
malpractice claims. Across all the studies, an average of 2.4 errors
was recorded for each procedure, although this figure rose to 15.5
when an independent observer recorded the errors. Equipment and/or
technology issues accounted for almost a quarter (23.5%) of these
Eight studies categorised the different types of equipment error:
the configuration or settings caused problems in more than four out
of 10 cases (43.4%); availability of the required device/machine was
an issue in just over 37% of cases; while in almost a third of
cases, the equipment or technology wasn’t working properly.
Four studies looked at the severity of mistakes in the operating
room, classifying a fifth as 'major', of which equipment failures
accounted for a fifth, compared with 8% and 13%, respectively, for
communication and technical failures.
While the type and rate of equipment failures varied widely,
depending on the study and surgical procedure involved, surgery that
relied heavily on technology had higher rates of problems.
Three studies reported on the deployment of an equipment/
technology checklist before surgery and showed that this could halve
the error rate, prompting the authors to recommend that a generic
equipment check should become routine practice, and be included in
the current World Health Organization Surgical Safety Checklist.
The authors appreciate that technological advances have improved
the chances of survival and quality of life of people undergoing
surgery. But they caution: “The increasing use of technology in all
surgical specialties may also increase the complexity of the
surgical process, and may represent an increasing propensity to
error from equipment failure.”
Previous evidence suggests that medical errors affect up to 16%
of all patients admitted to hospital, around half of which are
attributable to surgical procedures, they add.