Case report:

“… inadvertent pneumothorax during laparoscopic surgery, chest xray confirmed, requested chest drain and bottle kit, none to be found in hospital. We are the only theatre department in the trust who keep these drains… theatres ordered on top up yesterday on the back of this incident, maybe the other sites need to consider ordering in case of this rare emergency. We managed to get one sent from [a surgical ward]. As a rule we keep these for the thoracoscopy lists which had use our remaining stock the previous week. The store people had not placed an ordered for replacement stock. This has now been rectified.            Store people are now aware to have this available or highlight to manager or coordinator when emergency kit is unavailable.”

Commentary:

Dialogue between clinicians and those staff responsible for procurement and stocking is vital. Changes to stock levels or to the specific items stocked should never be implemented without involvement of clinicians. Organisations should have a nominated clinician with responsibility for this, with whom procurement and store room staff should liaise[1]. We repeatedly hear stories that suggest this relationship is not always thoroughly embedded in all organisations.

Reference:

[1] Chapter 2: Guidelines for the Provision of Anaesthesia Services for the Perioperative Care of Elective and Urgent Care Patients 2023. Guidelines for the Provision of Anaesthetic Services, Recommendation 7.9