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Developing Patient Safety Practices in Surgery
- 1. Developing Patient Safety Practices in Surgery GOPAL SEDAIN NEUROSURGEON INSTITUTE OF MEDICINE
- 2. Conflict of Interest Safety of patients
- 4. Background facts Under recognized Public health Issue 234 million operations are done globally each year An estimation of the global volume of surgery: a modelling strategy based on available data Weiser, Lancet 2008 .. 0 50,000,000 100,000,000 150,000,000 200,000,000 250,000,000 Incident HIV Cases Prevalent HIV Cases Childbirths Operations
- 5. Background facts • Known surgical complications ~ 3-16% • Known death rates ~ 0.4-0.8% At least 7 million disabling complications – including 1 million deaths – worldwide each year =
- 6. Background facts ~1500- 2500 wrong site surgery incidents every year in the US.¹ Giving antibiotics within one hour before incision can cut the risk of surgical site infection by 50%¹ In a survey of 1050 hand surgeons, 21% performed wrong-site surgery at least once in their career.² Communication is a root cause of nearly 70% of the events reported to the Joint Commission from 1995-2005.2 ¹ Seiden, Archives of Surgery, 2006. ² Joint Commission, Sentinel Event Statistics, 2006.
- 7. Wrong patient/ Wrong site Wrong Patient errors in diagnosis(56 %) errors in communication (100 %) Wrong site errors in judgment (85 %) lack of performing a surgical “timeout”(72 %) Stahel PF, Wrong site and wrong patient procedures in the era of the Universal Protocol – analysis of a prospective database of physician self-reported occurrences. Arch Surg. 2010;145:78–84.
- 8. Site marking Member of the surgical team Pre operative Involve patient Unambiguous with initials of marking person Permanent marker YES, GO, CORRECT SITE (not a cross, X)
- 9. Safe Surgery Objectives: WHO 1. Operate on the correct patient at the correct site. 2. Use methods known to prevent harm from administration of anesthetics 3. Recognize and effectively prepare for life-threatening loss of airway or respiratory function 4. Recognize and effectively prepare for risk of high blood loss 5. Avoid inducing an allergic or adverse drug reaction for which the patient is known to be at significant risk.
- 10. Safe Surgery Objectives: WHO 6. Consistently use methods known to minimize the risk for surgical site infection 7. Prevent inadvertent retention of instruments or sponges in surgical wounds 8. Secure and accurately identify all surgical specimens 9. Effectively communicate and exchange critical information for the safe conduct of the operation 10.Hospitals and public health systems will establish routine surveillance of surgical capacity, volume and results
- 11. Never Events!
- 16. CHECK LIST IMPLEMENTATION Baseline Checklist P value Cases 3733 3955 - Death (Mortality) 1.5% 0.8% 0.003 Any Complication(Morbidity) 11.0% 7.0% <0.001 SSI 6.2% 3.4% <0.001 Unplanned Reoperation 2.4% 1.8% 0.047 Haynes et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. NEJM 360:491-9. (2009)
- 17. KUMJ;2021 n=118 aware: 90% unwilling : 50% never used: 40%
- 18. Using The Check List We have to make that possible a mission. The Onus is on Surgeons as “Captain of the Ship” and Team leader Currently, hospitals do MOST of the right things, on MOST patients, MOST of the time. The Checklist helps us do ALL the right things, on ALL patients, ALL the time
- 19. Surgical Skills Technical Surgical Skills Non technical(NOTSS) communication teamwork leadership situation awareness decision-making problem-solving managing fatigue and stress task analysis
- 20. Swiss Cheese Model of Errors
- 21. Deadly Sins in Health care Arrogance Denial Blame Messenger shooting Averting gaze Hierarchies Passive learning
- 22. Blame Game
- 23. Way Forward Recognition: Recognize as a public health issue Surveillance: Produce data on surgery and outcomes Attitude: Use existing safety know-how
Editor's Notes
- Patient safety day : September 17 1 in 3 million: aviation 1 in 300;medicine
- degradation of the UP(Universal protocol” to a pure “robotic” ritual
- Institute can have its own protocol
- By the Team: perspective
- “Awake time Out “ with the patient
- NOTSS are Cognitive and Social Skills as surgical field has complex decision making situations
- Technical and Non technical Errors, system errors may line up to give untoward result “Reason"
- Harmful behaviours within health systems @ Donaldson