Open Access Open Badges Case report

A clinical "near miss" highlights risk management issues surrounding ultrasound-guided and wire-localised breast resections

Daniel Richard Leff12, Charles Vincent1, Ragheed Al-Mufti2, Deborah Cunningham3, Ara Darzi12 and Dimitri J Hadjiminas2*

Author Affiliations

1 Centre for Patient Safety and Service Quality (CPSSQ), Department of Bio surgery and Surgical Technology, Imperial College London, London, United Kingdom

2 Department of Breast Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom

3 Department of Radiology, Imperial College Healthcare NHS Trust, London, United Kingdom

For all author emails, please log on.

Patient Safety in Surgery 2012, 6:15  doi:10.1186/1754-9493-6-15

Published: 16 July 2012



The introduction of the National Health Service (NHS) Breast Screening Programme has led to a considerable increase in the detection of impalpable breast cancer. Patients with impalpable breast cancer typically undergo oncological resection facilitated either by the insertion of guide wires placed stereo-tactically or through ultra-sound guided skin markings to delineate the extent of a lesion. The need for radiological interventions on the day of surgery adds complexity and introduces the risk that a patient may accidentally transferred to the operating room directly without the image guidance procedure.

Case report

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.

Breast; Cancer; Ultrasound; Mammography; Wire