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Documentation, relating to surgical error.


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Documentation, relating to surgical error.

  2. 2. SURGERY An estimated 234 million major operations are performed around the world each year, which equals one operation for every 25 people alive. Each year an estimated 63 million people undergo surgical treatment due to traumatic injuries, another 10 million operations are performed for pregnancy- related complications, and 31 million more are undertaken to treat malignancies.
  3. 3. RAISING THE STANDARD TO MAKE SURGICALCARE SAFER WORLDWIDE Surgical care has been an essential component of health systems worldwide for more than a century. Although there have been major improvements over the last few decades, the quality and safety of surgical care has been dismayingly variable in every part of the world. The Safe Surgery Saves Lives initiative aims to change this by raising the standards that patients anywhere can expect.’
  4. 4. 5 FACTS ABOUT SURGICAL SAFETY 1. Complications after inpatient operations occur in up to 25% of patients. 2. The reported crude mortality rate after major surgery is 0.5–5%. 3. In industrialized countries nearly half of all adverse events in hospitalized patients are related to surgical care. 4. At least half of the cases in which surgery led to harm are considered to be preventable. 5. Known principles of surgical safety are inconsistently applied even in the most sophisticated settings.
  5. 5. WRONG-SITE SURGERY (WSS)What is it? Top Causes Wrong site  70% communication Wrong patient failure Wrong procedure  64% procedural non compliance  46% leadership issues
  6. 6. WSS RISK FACTORS  Emergency cases  Multiple surgeons  Multiple procedures  Deformities  Obesity  Time pressures  Unusual equipment or set up  Room changes
  7. 7. UNIVERSAL PROTOCOL - PREOPERATIVEVERIFICATION PROCESSPurpose Process To ensure that all of the relevant  An ongoing process of documents and studies are available prior to the start of the information gathering and procedure and that they have verification been reviewed and are consistent with each other and  Begins with the with the patients expectations determination to do the and with the teams procedure, continuing understanding of the intended patient, procedure, site, and, as through all settings and applicable, any implants. interventions involved in the Missing information or preoperative preparation of discrepancies must be the patient, up to and addressed before starting the including the "time out" just procedure. before the start of the procedure.
  8. 8. UNIVERSAL PROTOCOL - MARKING THEOPERATIVE SITEPurpose Process To identify  For procedures involving right/left unambiguously the distinction, multiple intended site of incision structures (such as or insertion. fingers and toes), or multiple levels (as in spinal procedures), the intended site must be marked such that the mark will be visible after the patient has been prepped and draped.
  9. 9. UNIVERSAL PROTOCOL - "TIME OUT" IMMEDIATELYBEFORE STARTING THE PROCEDUREPurpose Process To conduct a final  Active communication verification of the among all members of correct the surgical/procedure patient, procedure, site team, consistently initiated by a designated and, as member of the team, applicable, implants. conducted in a "fail-safe" mode, i.e., the procedure is not started until any questions or concerns are resolved.
  10. 10. FIVE STAGES OF THE ‘CORRECT PATIENT, CORRECTSITE AND CORRECT PROCEDURE’ POLICY Step 1: ensure that valid informed consent has been obtained Step 2: Confirm the patient’s identity Step 3: mark the site of the surgery or invasive procedure Step 4: Take a final ‘team time-out’ in the operating theatre, treatment or examination area. Step 5: ensure the correct and appropriate documents and diagnostic images are available
  11. 11. REFERENCES Correct Patient, Correct Procedure and Correct Site Policy and Guidelines for Western Australian Health Services. (2006). Retrieved January, 2, 2012, from p/Correct_Patient_Policy_and_Guidelines_Final.pdf Mulloy, D., & Hughes, R. (2008). Wrong-Site Surgery: A Preventable Medical Error. Retrieved January 2, 2012, from Safe Surgery Saves Lives. (2008). Retrieved January 2, 2012, from SSSL_Brochure_finalJun08.pdf Surgical Safety Checklist. (2009). Retrieved January 2, 2012, from ng_Checklist.pdf