%0 Journal Article
%T A clinical "near miss" highlights risk management issues surrounding ultrasound-guided and wire-localised breast resections
%A Daniel Richard Leff
%A Charles Vincent
%A Ragheed Al-Mufti
%A Deborah Cunningham
%A Ara Darzi
%A Dimitri Hadjiminas
%J Patient Safety in Surgery
%D 2012
%I BioMed Central
%R 10.1186/1754-9493-6-15
%X A case is described of a patient who required a pre-operative ultrasound scan in order to localise an impalpable breast cancer but who was accidentally taken directly to the operating theatre (OR) and anaesthetised without pre-operative intervention. The radiologist was called to the OR and an on-table ultrasound was performed without further consequence.It is evident that breast cancer patients undergoing image-guided resection are exposed to an additional layer of clinical risks. These risks are not offset by the World Health Organisation surgical safety checklist in its present guise. Here, we review a number of simple and inexpensive changes to the system that may improve the safety of the breast cancer patient undergoing surgery.
%K Breast
%K Cancer
%K Ultrasound
%K Mammography
%K Wire
%U http://www.pssjournal.com/content/6/1/15/abstract