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NPSA issues guidance to avoid wrong-site cranial burr holes

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The government’s patient safety watchdog has issued new guidance to prevent burr holes being drilled in the wrong side of patients’ heads during craniotomy procedures.

According to the National Patient Safety Agency, there were 15 incidents over the last three years where burr holes where drilled in the wrong side of the cranium.

None of these were reported as deaths, but the NPSA believes all the errors could have been prevented if neurosurgical teams carried out basic preliminary checks.

During craniotomy, holes are drilled into the patient’s skull to treat brain traumas and relieve intracranial pressure in emergencies.

Key actions include marking the side of intended surgery with imaging notes and patient consent.

The patient carer should be involved in the discussion to confirm the operative side, and the procedure should be carried out by a surgeon.

A ‘Time Out’ must take place in theatre before final positioning, head pins are inserted or an incision is made, where the patient’s name, the procedure, the correct side with reference to imaging and clinical records are confirmed.

Local practice should be audited and staff encouraged to report further incidents. The actions follow the general principles of sign in – time out – sign out identified by the WHO safer surgery checklist, published in June 2008.

For more details, visit the NPSA website.


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