[Skip to content]

Search our Site
National Patient Safety Agency

New guidance for neurosurgical teams to avoid wrong side burr holes

Wednesday 12 November 2008


Today (12 November) new guidance has been issued to neurosurgical teams in England and Wales alerting them to incidents of wrong site surgery and the measures they can take to prevent similar incidents from happening in future.


The alert comes from the National Patient Safety Agency (NPSA) and applies to neurosurgical teams in all NHS trusts in England and Wales, as well as the independent sector.


It focuses on the risks of a neurosurgical procedure (craniotomy) where holes are drilled into the patient’s skull to treat brain traumas as well as to relieve intracranial pressure in emergencies.


The NPSA is aware of 15 incidents between January 2005 and September 2008 where these holes have been drilled on the wrong side of the patient’s head. Although none of these were reported as deaths the NPSA believes that all of these errors could have been prevented if the neurosurgical teams had carried out basic preliminary checks.


Kevin Cleary, Medical Director of the NPSA said:


“These incidents reveal that staff are not always following best practice procedures for pre-surgery checks and this is causing avoidable errors to occur in our neurosurgical units in the NHS. The NPSA has identified common problem areas, such as staff failing to mark the patient to show the side for surgery before they go into theatre, vital information not being included on the operating list and patient consent form, and staff failing to challenge the surgeon once they notice that surgery has started on the wrong side. Our Rapid Response Report gives explicit guidance on the marking and checking procedures that the neurosurgical team should follow prior to commencing surgery. This is in line with the latest guidelines set by the World Health Organisation. It is a requirement that they are adopted in all neurosurgical settings.”


The alert is the latest in the NPSA’s series of Rapid Response Reports. It follows the World Health Organisation’s Surgical Safety Checklist which was launched in June 2008 and highlighted by Chief Medical Officer Sir Liam Donaldson in his Annual Report this July. The Checklist identifies a set of surgical safety standards for surgical teams to use in operating theatres, as part of a major drive to make surgery safer around the world.


The NPSA has worked closely with relevant surgical expertise to develop the alert, namely the Royal College of Surgeons of England, Neuroanaesthesia Society of Great Britain and Ireland and the Society of British Neurological Surgeons.


John Black, President of the Royal College of Surgeons of England said:


“Team work is vitally important in an operating theatre and every member of the team needs to be clear on the correct procedures to follow and to have the confidence to question the team leader at any point in an operation if they think there is a problem.  This report builds on the work the College has done with the NPSA to give clear guidance on how you mark up a patient’s body for neurosurgery.


“There are always improvements we can make and I encourage every member of the surgical team to report near misses or actual incidents so we can continue to work in partnership with the NPSA to ensure the best possible patient safety across the board.”


Phillip van Hille, President of the Society of British Neurological Surgeons said:


“The Society of British Neurological Surgeons supports this Rapid Response Report. Neurosurgery is committed to the highest standards of patient care and wishes to do everything possible to avoid wrong-side cranial surgery. This has been a particular problem when emergency surgery is undertaken for patients who are unable to confirm the side of their intracranial pathology, or have bilateral pathology or whose surgery is based on imaging acquired in other hospitals.


“The Society considers that appropriate pre-operative marking may help reduce the risks of wrong-site surgery. The Society strongly supports the final pre-operative (“time-out”) check in theatre before patients are finally positioned and prepared for surgery“.


View the Rapid Response Report on Avoiding wrong side burr holes / craniotomy.




Notes for editors:


  1. Media enquiries to Paul Cooney in the NPSA Press Office on 020 7927 9351 or paul.cooney@npsa.nhs.uk.
  2. In July 2008 the World Health Organisation launched its campaign, “Safe Surgery Saves Lives” to reduce the number of errors occurring in surgery. The focus of the campaign is the Surgical Safety Checklist, which identifies three phases of an operation, each corresponding to a specific period in the normal flow of work: before the induction of anaesthesia ("sign in"), before the incision of the skin ("time out") and before the patient leaves the operating room ("sign out"). In each phase, a checklist coordinator must confirm that the surgery team has completed the listed tasks before it proceeds with the operation.
  3. Chief Medical Officer, Sir Liam Donaldson, endorsed the WHO Surgical Safety Checklist in his 2007 Annual Report, which was launched in July 2008.
  4. Since June 2007, the NPSA has been issuing notices with supporting information to NHS organisations about risks to patients. These are called Rapid Response Reports and 13 have been issued to date.  These are issued to all NHS organisations in England and Wales, presenting the evidence of harm to patients and identifying clear actions to reduce risks.
  5. The National Patient Safety Agency is a Special Health Authority of the NHS. It encompasses three divisions; the National Research Ethics Service, the National Reporting and Learning Service and the National Clinical Assessment Service. Each has its own sphere of expertise to improve patient outcomes. The NPSA’s vision is to lead and contribute to improved, safe patient care by informing, supporting and influencing healthcare individuals and organisations. For more information visit: www.npsa.nhs.uk.