Keynote talk delivered at New Jersey Hospital Association Seminary on Improving Surgical Safety & Patient Outcomes held on September 25, 2013 at their Conference Center in Princeton New Jersey. Over physicians, administrators, nurses and perioperative services providers in attendance.
WHO has undertaken a number of global and regional initiatives to address surgical safety. The Global Initiative for Emergency and Essential Surgical Care and the Guidelines for Essential Trauma Care focussed on access and quality. The Second Global Patient Safety Challenge: Safe Surgery Saves Lives addresses the safety of surgical care.
Learn about the principles behind the surgical checklist and the evidence for adopting the checklist and how one NHS Board has applied the checklist to their surgical theatres and how another has expanded the checklist principle to other areas.
The World Health Organisation is a global tool to ensure safety in surgery. The principles and procedures are described for how to implement it in your organisation.
Purpose of the call:
•Review current data and state of the SSCL
•Discuss the role of communications and team work in patient safety
•Discuss and define how we can measure the effectiveness of the SSCL.
Read more and watch the webinar recording: http://bit.ly/1sXDqaZ
1. Safety is everybody’s business. According the Hippocratic oath from 5th century : “ Never do harm to anyone” Safer Surgery can be defined as a reduction in avoidable harm to a surgical patient
2. It is a part of medical specialty that uses operative manual and instrumental technique on a patient to investigate or treat a pathological condition. Surgical team: 1. Surgeon 2. Surgeon’s assistance 3. Anesthetist 4. Scrub nurse 5. Scouting nurse 6. Surgical technologist
3. Time or duration when patient admitted and discharge after completion of surgery. So, surgical safety has broadly included in different phases: 1. Preoperative(Diagnosis, investigation) 2. Per operative 3. Postoperative(Up to discharge)
4. 1. Adverse events: An incident which result in harm to the patient. 2. Near Miss: An incident which could resulted in unwanted harm but did not. 3. No-harm events: An incident that occur and reach to the patient but result in no injury.
5. An article in the Gurdian newspaper UK in March 2013 claimed that “five worst medical” nightmares a Pt faces, three related to surgery: 1. Wrong site surgery 2. Wrong patient surgery 3. Retained instruments and swabs The rate of harm in surgical patient is unknown but probably occur in about 10% surgical patient, though much of this harm will be minor.
6. 1. Patients themselves. 2. Healthcare professional 3. System failure. 4. Medical complexity
7. Patients Themselves 1. A variety of presentation. 2. Differing co-morbidities 3. Differing response to treatment 4. Patients are reluctant to speak up. 5. Refuse to co-operate 6. Hide and seek
8. Healthcare professional 1. Inadequate Pt assessment(delay or error in Diagnosis) 2. Failure to use or interpret appropriate test 3. Error in performance of an operation and test. 4. Inadequate monitoring or follow-up. 5. Deficient training or experience 6. Fatigue, overwork or time pressure. 7. Personal or psychological factor i.e. drug abuse or depression. 8. Lack of recognition of the danger of medical errors.
9. System failure 1. Poor communication between healthcare provider. 2. Inadequate staffing level 3. Overreliance on investigation 4. Lack of coordination at handover 5. Drug similarities. 6. Equipment failure due to lack of skilled operators. 7. Inadequate system to report and review patient safety incident.
10. Medical complexity 1. Advance and new technologies(laparoscopic, robotic surgery) 2. Potent drug and their side effects and interaction. 3. Working environment- Surgical ICU, HDU and Operation theatre
11. Surgery is one of the most complex health intervention to deliver. More than 100 million people worldwide require surgical treatment every year for different reason. Great Professor of Surgery Sir Alfred Cuschieri and other describes surgical errors in different categories that committed by the surgeons during care of the Patients.
12. 1. Diagnosis and management erro
WHO has undertaken a number of global and regional initiatives to address surgical safety. The Global Initiative for Emergency and Essential Surgical Care and the Guidelines for Essential Trauma Care focussed on access and quality. The Second Global Patient Safety Challenge: Safe Surgery Saves Lives addresses the safety of surgical care.
Learn about the principles behind the surgical checklist and the evidence for adopting the checklist and how one NHS Board has applied the checklist to their surgical theatres and how another has expanded the checklist principle to other areas.
The World Health Organisation is a global tool to ensure safety in surgery. The principles and procedures are described for how to implement it in your organisation.
Purpose of the call:
•Review current data and state of the SSCL
•Discuss the role of communications and team work in patient safety
•Discuss and define how we can measure the effectiveness of the SSCL.
Read more and watch the webinar recording: http://bit.ly/1sXDqaZ
1. Safety is everybody’s business. According the Hippocratic oath from 5th century : “ Never do harm to anyone” Safer Surgery can be defined as a reduction in avoidable harm to a surgical patient
2. It is a part of medical specialty that uses operative manual and instrumental technique on a patient to investigate or treat a pathological condition. Surgical team: 1. Surgeon 2. Surgeon’s assistance 3. Anesthetist 4. Scrub nurse 5. Scouting nurse 6. Surgical technologist
3. Time or duration when patient admitted and discharge after completion of surgery. So, surgical safety has broadly included in different phases: 1. Preoperative(Diagnosis, investigation) 2. Per operative 3. Postoperative(Up to discharge)
4. 1. Adverse events: An incident which result in harm to the patient. 2. Near Miss: An incident which could resulted in unwanted harm but did not. 3. No-harm events: An incident that occur and reach to the patient but result in no injury.
5. An article in the Gurdian newspaper UK in March 2013 claimed that “five worst medical” nightmares a Pt faces, three related to surgery: 1. Wrong site surgery 2. Wrong patient surgery 3. Retained instruments and swabs The rate of harm in surgical patient is unknown but probably occur in about 10% surgical patient, though much of this harm will be minor.
6. 1. Patients themselves. 2. Healthcare professional 3. System failure. 4. Medical complexity
7. Patients Themselves 1. A variety of presentation. 2. Differing co-morbidities 3. Differing response to treatment 4. Patients are reluctant to speak up. 5. Refuse to co-operate 6. Hide and seek
8. Healthcare professional 1. Inadequate Pt assessment(delay or error in Diagnosis) 2. Failure to use or interpret appropriate test 3. Error in performance of an operation and test. 4. Inadequate monitoring or follow-up. 5. Deficient training or experience 6. Fatigue, overwork or time pressure. 7. Personal or psychological factor i.e. drug abuse or depression. 8. Lack of recognition of the danger of medical errors.
9. System failure 1. Poor communication between healthcare provider. 2. Inadequate staffing level 3. Overreliance on investigation 4. Lack of coordination at handover 5. Drug similarities. 6. Equipment failure due to lack of skilled operators. 7. Inadequate system to report and review patient safety incident.
10. Medical complexity 1. Advance and new technologies(laparoscopic, robotic surgery) 2. Potent drug and their side effects and interaction. 3. Working environment- Surgical ICU, HDU and Operation theatre
11. Surgery is one of the most complex health intervention to deliver. More than 100 million people worldwide require surgical treatment every year for different reason. Great Professor of Surgery Sir Alfred Cuschieri and other describes surgical errors in different categories that committed by the surgeons during care of the Patients.
12. 1. Diagnosis and management erro
This presentation was prepared by RUTAYISIRE François Xavier and ISHIMWE Diane, Medical students in Year 4(Doctorate 2) at University of RWANDA school of medicine and Pharmacy, Department of Medicine and Surgery. we did the work under supervision of Dr Ntakiyiruta Georges,Mmed,FCSECSA
This presentation was done by RUTAYISIRE François Xavier and ISHIMWE Diane, medical students at University of RWANDA School of Medicine and pharmacy, department of medicine and surgery. They did it while they were in Year 4 (Doctorate2), under supervision of Dr Ntakiyiruta Georges,Mmed,FCSECSA. It tell us about what a surgical safety checklist is, and why is it important in surgical field.
Experience with the implementation of the WHO checklist and briefing in the operating theatre. Krishna Moorthy. IV Internacional Conference on Patient Safety. (Madrid, Ministry of Health and Consumer Affairs, 2008)
Surgical safety checklist issued by whoVin Williams
QPG learning sharing one of the checklist issued by WHO to be followed by surgeons , nurses and anesthetists during whole #surgery to maintain quality in surgical process
oint Commission International Accreditation Standards for Hospitals, 6th Edition, provides the basis for accreditation of hospitals throughout the world. Joint Commission International (JCI) standards define the performance expectations, structures, and functions that must be in place for a hospital to be accredited by JCI. The standards are divided into two main sections: 1) patient-centered care and 2) health care organization management.
The correct application of the safety check steps in our routine theatre operations and procedures will greatly reduce surgically related mortality and morbidity.
In the presentation, a summary of initiatives to be taken by hospitals in different areas for patient safety have been described for the knowledge, practices and implementation of patient safety initiative by hospital managers/Administrators.
Surgical Education Research: Tips, Skills and Opportunities r_ajjawi
In this interactive workshop we aim to familiarise participants with ways in which surgical educational research is carried out, especially highlighting how it differs from more familiar biomedical approaches. In doing so we will:
- Provide exemplars of educational research carried out by surgeon educators
- Discuss challenges and identify opportunities for developing oneself as a researcher in surgical education.
This presentation was prepared by RUTAYISIRE François Xavier and ISHIMWE Diane, Medical students in Year 4(Doctorate 2) at University of RWANDA school of medicine and Pharmacy, Department of Medicine and Surgery. we did the work under supervision of Dr Ntakiyiruta Georges,Mmed,FCSECSA
This presentation was done by RUTAYISIRE François Xavier and ISHIMWE Diane, medical students at University of RWANDA School of Medicine and pharmacy, department of medicine and surgery. They did it while they were in Year 4 (Doctorate2), under supervision of Dr Ntakiyiruta Georges,Mmed,FCSECSA. It tell us about what a surgical safety checklist is, and why is it important in surgical field.
Experience with the implementation of the WHO checklist and briefing in the operating theatre. Krishna Moorthy. IV Internacional Conference on Patient Safety. (Madrid, Ministry of Health and Consumer Affairs, 2008)
Surgical safety checklist issued by whoVin Williams
QPG learning sharing one of the checklist issued by WHO to be followed by surgeons , nurses and anesthetists during whole #surgery to maintain quality in surgical process
oint Commission International Accreditation Standards for Hospitals, 6th Edition, provides the basis for accreditation of hospitals throughout the world. Joint Commission International (JCI) standards define the performance expectations, structures, and functions that must be in place for a hospital to be accredited by JCI. The standards are divided into two main sections: 1) patient-centered care and 2) health care organization management.
The correct application of the safety check steps in our routine theatre operations and procedures will greatly reduce surgically related mortality and morbidity.
In the presentation, a summary of initiatives to be taken by hospitals in different areas for patient safety have been described for the knowledge, practices and implementation of patient safety initiative by hospital managers/Administrators.
Surgical Education Research: Tips, Skills and Opportunities r_ajjawi
In this interactive workshop we aim to familiarise participants with ways in which surgical educational research is carried out, especially highlighting how it differs from more familiar biomedical approaches. In doing so we will:
- Provide exemplars of educational research carried out by surgeon educators
- Discuss challenges and identify opportunities for developing oneself as a researcher in surgical education.
To increase the effectiveness of the incident analysis in improving care, analysis can’t be addressed in isolation from incident management (the multitude of activities that take place before and after an incident). Three main topics will be covered in this module: the main steps in the incident management continuum; differentiating between incident analysis (focused on system improvement) and accountability reviews (focused on individual performance), and selecting an incident analysis method.
Are we using the correct quality goals?Ola Elgaddar
Setting quality goals / specifications is a debatable issue since 1999. I am trying here to show the options and the continuos trials from several professional bodies to reach a consensus in this matter.
This was an oral presentation in the first international conference of the Chemical Pathology Department, Medical Research Institute, Alexandria University - February 2016
Why Process Measures Are Often More Important Than Outcome Measures in Health...Health Catalyst
The healthcare industry is currently obsessed with outcome measures — and for good reason. But tracking outcome measures alone is insufficient to reach the goals of better quality and reduced costs. Instead, health systems must get more granular with their data by tracking process measures. Process measures make it possible to identify the root cause of a health system’s failures. They’re the checklists of systematically guaranteeing that the right care will be delivered to every patient, every time. By using these checklists, organizations will be able to improve quality and cost by reducing the amount of variation in care delivery.
Mr James Downie, CEO, presented on the topic 'Moving towards value based funding' at the 2017 Activity-Based Funding Conference, hosted by the Health Service Executive, Ireland on 11 May 2017.
Decisio Health provides an FDA cleared class II medical device that displays real-time actionable information with the goal of increasing clinical guideline adherence, which has been shown to improve clinical outcomes and reduce hospital costs. It is a clinical decision support tool for use in hospitals.
NVTC Capital Health Tech Summit: Dr. Shannon KeynoteAlexa Magdalenski
The 2017 Capital Health Tech Summit took place on June 15, 2017 at the Inova Center for Personalized Health. Dr. Richard Shannon, Executive Vice President, Health Affairs, University of Virginia provided the Summit's second keynote.
Realizing the Promise of Patient-Reported Outcomes MeasuresHealth Catalyst
Dr. Rachel Clark Sisodia, a champion of the system-wide adoption of Patient Reported Outcomes Measures at Partners HealthcCare, will share her experience and perspective on the relevance and necessity of Patient-Reported Outcomes Measures (PROMs). In this webinar, Dr. Sisodia will highlight how the PROMs ideas have been put into practice at Partners HealthCare.
Join us and learn:
Strategies and tactics for overcoming potential barriers to collecting and effectively using PROMs.
Through specific examples, how to demonstrate that PROMs can help deliver faster, more personalized care for individual patients.
How to collect and use advanced analytics to leverage aggregate PROMs data to inform clinical patient and provider decisions.
How to use outcomes metrics for quality improvement and comparative effectiveness.
Mr James Downie, CEO, presented on the topic 'IHPA 2017 and beyond' at the Enhancing Performance & Efficiency in Paediatric Care - CHA Annual Benchmarking Forum, hosted by Children's Healthcare Australasia on 25 May 2017.
Clinical Science for Medical Devices: A Guide for Entrepreneurs | Jim Gustafs...UCICove
About UCI Applied Innovation:
UCI Applied Innovation is a dynamic, innovative central platform for the UCI campus, entrepreneurs, inventors, the business community and investors to collaborate and move UCI research from lab to market.
About the Cove @ UCI:
To accelerate collaboration by better connecting innovation partners in Orange County, UCI Applied Innovation created the Cove, a physical, state-of-the-art hub for entrepreneurs to gather and navigate the resources available both on and off campus. The Cove is headquarters for UCI Applied Innovation, as well as houses several ecosystem partners including incubators, accelerators, angel investors, venture capitalists, mentors and legal experts.
Follow us on social media:
Facebook: @UCICove
Twitter: @UCICove
Instagram: @UCICove
LinkedIn: @UCIAppliedInnovation
For more information:
cove@uci.edu
http://innovation.uci.edu/
Similar to Improving Surgical Safety and Patient Outcomes (20)
Presentation delivered during a Hospital Efficiency Seminar hosted by Institute for Healthcare Optimization on July 25, 2013. Reviews Mayo Clinic experience and outcomes with using variability theory to re-design the management of the operating rooms at Mayo Clinic Florida.
SureSELECT - Operating Room and Hospital Resource Utilization Schedule Optimi...C Daniel Smith
Optimizing the flow of a surgical patient through the operating room helps ensure the greatest value in the care of that patient. To achieve this optimized flow, the resources needed to provide care through the entire episode of care need to be coordinated.
Coordinating these varied and often disintegrated resources is often nearly impossible without the dedicated time of multiple FTEs to manage the schedules and resources of the different segments of care.
The starting point for the flow of a surgical patient is their placement on the operating room schedule. SureSELECT surveys and assesses all the resources needed for a specific patient’s care and provides the optimized placement on the operating room schedule to achieve optimal flow. Proprietary algorithms assure that all resources are available “just-in-time” throughout the patient’s care.
Re-engineering the Operating Room Using Variability Methodology to Improve He...C Daniel Smith
Hospitals across the country are aggressively pursuing cost-cutting strategies, and the high-value, high-cost environment of the operating room is a prime target for cost reduction.
Applying variability methodology swings the pendulum for access to the hospital’s operating rooms from “whatever and whenever” the surgeon wants, to what is best for the hospital. Put more directly, in this model, the surgeon is asked to compromise to meet the hospital’s financial needs. The resultant tension between a surgeon and hospital administration can become intense and was certainly present during the redesign and implementation detailed in this case study.
Software and information technology tools to help schedule surgical cases within the redesign goals, and reporting tools within a quantitative dashboard are essential to facilitate adoption of this program. Transparency regarding leadership decisions and frequent feedback to all providers about performance improvements should be emphasized. Change management and analytics support should be identified either internally or pursued externally before starting such a program.
Surgery Grand rounds Presentation at Rush University Medical Center on March 20, 2013. Presentation highlights clinical use of Prone Thoracoscopy, Fluorescence Angiography, Transcervical Videoscopic Esophageal Dissection (TVED) and Linx.
Slides from recent presentation at Mayo Clinic course on advances in gastroenterology. These are the slides that are a part of the video presentation of this same talk.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
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Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Evaluation of antidepressant activity of clitoris ternatea in animals
Improving Surgical Safety and Patient Outcomes
1. Reducing Surgical-Related Harm
Through Improved Quality of Care
C. Daniel Smith, MD
New Jersey Hospital Association Partnership for Patients
Improving Surgical Safety and Patient Outcomes
September 25, 2013
1
2. • No financial or other relationship with any
product or treatment discussed in this talk
Conflict of Interest / Disclosure
3. Disclaimers
• I am not a quality or safety expert
• I am a surgeon and an innovator (really an early
adoptor)..innovation in practice, leadership
• Leading change at Mayo in Florida for 7 years
• Mayo in Florida has become a significant positive
outlier in many outcomes and safety measures
(NSQIP, FCIP, Leapfrog, USNWR, etc.)
• I will not tell you anything today you don’t already
know
4. Surgeon Characteristics
• Intelligent – typically at top of medical school class
• Well educated – competitive course of training, typically
10+ years postgraduate
• Strong – emotionally and physically demanding work
• Confident – Patients don’t want an unsure surgeon
• Action oriented – Like to fix problems and see
immediate results
• Unique – No one else in medicine quite the same
5. Surgeon Characteristics
• Big ego – it takes a big ego to cut people open. “Anyone
else does this and they go to jail, patients pay us to do this”
• Solo predator – had to compete for limited training
opportunities. The person next to you may take away your
future.
• OCD and Paranoid – healthy traits to prevent doing
something stupid or leaving something behind
• Martyr – uniquely retain the full spectrum of patient care.
“The rest of medicine is going to shift work and separate
inpatient/outpatient teams”
• Special – “other than God, no one else can see and touch
what’s inside my body”
6. Today’s Goals/Objectives
• Construct for pursuing improved
outcomes / safety in surgery
• Case study in SSI reduction
• Establishing a culture of safety
• Q&A
6
7. Healthcare Delivery Goals
7
To provide the right care
To the right patient
At the right time
In the right place
Value =
Quality*
Cost
*Outcomes, Safety, Service
8. How Are We Doing?
• 44,000-98,000 Americans die in
hospitals as result of medical
error
• $37.6 billion from adverse events
• $17 billion preventable adverse
events
• More die from medical error than
from highway accidents or breast
cancer
November 1999
9. Never Events in Surgery
Electrical /
Thermal Injury
Specimen
Error
Medication
Error
Blood Products
Error
Patient
Fall
Drug Diversion
Wrong Site
Surgery
Wrong Patient
Surgery
Wrong
Procedure
Retained
Foreign Body
Operative
Death
10. Never Events in Surgery
312 Never Events reported to
Minnesota Department of Health
2007-2008
12. Never Events in Surgery
A surgeon in the United States leaves a foreign
object such as a sponge or towel inside a
patient's body after an operation 39 times a week,
performs the wrong procedure on a patient 20
times a week, and operates on the wrong body
site 20 times a week.
Surgery 2013;153:465-72.
13. Healthcare Delivery Goals
13
To provide the right care
To the right patient
At the right time
In the right place
Value =
Quality*
Cost
*Outcomes, Safety, Service
15. Value Equation – Quality Defined
• Outcome – a final result; end product
• Safety – freedom from harm, danger or
injury
• Service – the action of helping or doing
work for someone
15
16. Value Equation – Quality Measured
• Outcome
• Safety
• Service
16
Unexpected return to OR
Transfusion requirement
LOS
OR time
Complication
17. Value Equation – Quality Measured
• Outcome
• Safety
• Service
17
Never events
UP compliance
STOP sign compliance
18. Value Equation – Quality Measured
• Outcome
• Safety
• Service
18
Patient satisfaction survey
Call to appointment
Door-to-OR
19. Value Equation – Quality Quantified
• Outcome
• Safety
• Service
19
Unexpected return to OR
Transfusion requirement
LOS
OR time
Complication
Never events
UP compliance
STOP sign compliance
Patient satisfaction survey
Call to appointment
Door-to-OR
20. Value Equation – Quality Quantified
• Outcome
• Safety
• Service
20
Unexpected return to OR
Transfusion requirement
LOS
OR time
Complication
Never events
UP compliance
STOP sign compliance
Patient satisfaction survey
Call to appointment
Door-to-OR
Assign a relative value to each
Plug into value equation
Plot changes/progress over time
21. The Value Equation Realized
21
Value =
Quality*
Cost
*Outcomes, Safety, Service
Unexpected return to OR
Transfusion requirement
LOS
OR time
Complication
Never events
UP compliance
STOP sign compliance
Patient satisfaction survey
Call to appointment
Door-to-OR
5.6 =
1350
241
*Outcomes, Safety, Service
23. Outcomes Improvement in Surgery
23
Processes
• Six Sigma
• LEAN
• CQI
• SCIP
• NSQIP
• BPBC
Standardizing a process
will result in improved
outcomes…generalized
from manufacturing
24. Outcomes Improvement in Surgery
24
Processes
• Six Sigma
• LEAN
• CQI
• SCIP
• NSQIP
• BPBC
A recent study performed across 112
Veterans Affairs hospitals and involving a
total of 60,853 operations found that the
implementation of the SCIP infection-
prevention measures did not yield
measurable improvement in SSIs at the
patient or hospital level or an improvement
in adjusted SSI rates over the im-
plementation period.
“although the processes measured are best
practices and should continue, they might be
too simplistic or blunt to discriminate hospital
quality”
Ann Surg 2011;254(3):494–9
25. Outcomes Improvement in Surgery
25
Processes Culture
• Process Improvement
• “Just do it”
• PDSA
• Rapid cycles of
change
≠
• Six Sigma
• LEAN
• CQI
• SCIP
• NSQIP
• BPBC
26. Outcomes Improvement in Surgery
26
SSI Case Study
Thompson KM, Oldenburg WA, Deschamps C, Rupp, W,
Smith CD. Chasing zero: the drive to eliminate surgical
site infections. Ann Surg 2011;254(3):430–6
27. Healthcare Associated Infections
• 1.7 million infections costing $45 billion
• Surgical site infections 2nd
most common HAI
• SSI is 2nd
only to medication error as adverse
event in hospitalized patient
• Estimated cost of additional $3,000 per SSI
infection
• Best practices for reducing SSI remains illusive
27
28. SSI Reduction Project - Aim
• Test the hypothesis that development of an
organized structure to facilitate rapid
development and diffusion of multiple
infection prevention strategies simultaneously
would result in lower rates of surgical site
infection
28
29. SSI Reduction Project - Aim
• Test the hypothesis that development of an
organized structure to facilitate rapid
development and diffusion of multiple
infection prevention strategies simultaneously
would result in lower rates of surgical site
infection
29
No single Process (e.g., SCIP) will
eliminate SSIs.
A BUNDLE of care based on Change &
Quality Improvement principles is more
likely to work.
Pursue an “SSI Elimination Bundle”
30. Mayo Clinic Culture
• Fully integrated healthcare practice
• Physician leadership (CEO)
• All physicians salaried
• No productivity-based financial
compensation adjustment
• Day-to-day operations managed by MD led
committees
30
31. Mayo Clinic Florida
• 214 bed hospital (19 ORs) and outpatient
practice within a single complex/campus
• 11,000 admissions/ year: 55% surgical
• Single electronic medical record and order
entry throughout practice
• 12,000 operations/year – complex case mix
(e.g., 150 liver transplants, 1,200 NS, 900
GISurg)
31
33. CEO Imperatives
• Focus on quality and safety
• “Just do it”
• Rapid cycle change
• Eliminate healthcare associated infections
• Leverage organization’s core values (needs of
patient come first, teamwork)
33
34. SSI Reduction Project - Design
• Project embedded in existing quality/safety
management structure
• Steering committee to oversee all aspects of project
including metrics and impact of interventions
• Evidence-based modifiable risk factors identified and
gap analysis performed
• Specific targets for improvement identified
• Multidisciplinary workgroups (frontline workers)
assigned each target
34
36. Pre-operative
1. Identify and treat all infections remote to
the surgical site before elective operation
2. Encourage smoking cessation within 30
days before procedure
3. Avoid immunosuppressive medications in
the perioperative period if possible
4. Preoperative antiseptic skin cleansing
5. Mechanical preparation of the colon for
colorectal surgery patients
6. Administer non-absorbable oral
antimicrobial agents on the day before
the operation
7. Screen and decolonize Staphylococcus
aureus carriers undergoing elective
procedures
8. Screen preop blood glucose levels in
patients undergoing select elective
procedures
Holding
9. Only remove hair that is will interfere
with the operation
10. Remove hair immediately before the
operation with clippers (SCIP 6)
Intra-operative
11. Select appropriate antibiotic based on the
surgical procedure (SCIP 2)
12. Increase dosing of prophylactic
antimicrobial agent for morbidly obese
patients
13. Administer prophylactic antimicrobial
agents IV on time (SCIP 1)
14. Use an appropriate antiseptic agent for
skin preparation
15. Maintain therapeutic levels of the
prophylactic antimicrobial agent
throughout the operation
16. Use at least 50% fraction of inspired
oxygen for select procedures
17. Keep OR doors closed during surgery
18. Maintain peri-operative normothermia
(SCIP 9)
19. Adhere to standard principles of
operating room asepsis
20. Optimize ventilation, environmental
cleaning and sterilization of surgical
equipment
21. Minimize flash sterilization
Post-operative
22. Adequately control serum blood glucose
levels in diabetic patients (SCIP 4)
23. Protect primary-closure incisions with a
sterile dressing for 24-48 hours
postoperatively
24. Discontinue the prophylactic
antimicrobial agent within 24 hours of
surgery (SCIP 3)
Surgeon Technique
25. Use appropriate antiseptic agent to
perform preoperative surgical scrub for
surgical team members
26. Handle tissue carefully and eradicate
dead space
27. Minimize operative time as much as
possible
Transparency
28. Feedback surgeon specific infection rates
SSI Reduction Project - Design
36
37. SSI Reduction Project - Design
Deploy in three phases concurrently
37
Phase One
Consistent delivery
of SCIP 1-3
interventions
Phase Two
Modifiable risk
factors with
scientific evidence
linked to SSI
reduction
Phase Three
Focus on intra-op
environment and
reporting
Preoperative
Evaluation
(POE) Clinic
38. SSI Reduction Project - Design
Deploy in three phases concurrently
38
Phase One
• Revise order sets
• On-time antibiotic
delivery
• EMR-based alerts
• Confirm antibiotics
during time out
• Clippers in OR
• Intraop normothermia
Phase Two
• S. aureus decolonization
• Standard periop skin
cleansing
• Intraop protocols for skin
prep, antibiotic dosing
and timing
• Hand hygiene
• Incision dressing – 24
hrs
Phase Three
• Intraop flow, attire,
coverings
• All-or-none metrics
Preoperative
Evaluation
(POE) Clinic
40. SSI Reduction Project - Communication
40
•CEO’s monthly Department Chair and
staff meetings
•HOS all staff meetings (MD, nursing,
support services)
•Standing item on Surgical Committee
agenda
•Workgroup reports to peers
42. SSI Reduction Project – Data
• Trained infection control practitioners
• NHSN definitions to identify and classify SSI
• Baseline SSI data collected from May 2008 –
Dec 2008
• Data collected thru Jun 2010 and analyzed
• Comparison to baseline and rolling 6-month
average
42
45. SSI Reduction Project - Results
• Case volume, RVU and case complexity unchanged
thru project period
• Of 10 surgical services involved:
7 experienced decrease in SSI
2 experienced increase in SSI
1 experienced no change in SSI
45
46. SSI Reduction Project - Summary
• Tactics to rapidly identify and optimize delivery of
recommended SSI risk reduction strategies is
possible on large scale
• Significant reduction in SSI was achieved
71% decrease in Class I SSI
49% decrease in Class II SSI
57% overall decrease in SSIs
• Estimated institutional cost savings of $668,000 -
$1,634,000/year*
46
* From R Scott. The direct medical costs of Healthcare-Associated Infections in
U.S Hospitals and the Benefits of Prevention
47. SSI Reduction Project - Observations
• Methodology embedded in existing quality/safety
culture
• Executive leadership driven
• Electronic medical record
• Communication & Transparency
• Multidisciplinary team-based
development/deployment
• No competing or conflicting individual $ incentives
47
48. SSI Reduction Project - Limitations
• Shotgun approach without defining specific actions
that correlate to results
• Absence of “All-or-None” metrics
• Observed reductions may be related to improved
culture, more attention from leadership, or
improved performance of surgical teams
• Short-term results
48
49. Value Equation – Quality Defined
• Outcome – a final result; end product
• Safety – freedom from harm, danger or
injury
• Service – the action of helping or doing
work for someone
49
50.
51.
52. Never Events in Surgery
A surgeon in the United States leaves a foreign
object such as a sponge or towel inside a
patient's body after an operation 39 times a week,
performs the wrong procedure on a patient 20
times a week, and operates on the wrong body
site 20 times a week.
Surgery 2013;153:465-72.
53. Safety in Surgery
53
Processes
• Time out
• Stop Sign
• Site Marking
• Universal protocol
• SBAR
• Crucial Conversations
• LEAN
• Six Sigma
Culture
54. Safety in Surgery
54
Processes
• Time out
• Stop Sign
• Site Marking
• Universal protocol
• SBAR
• Crucial Conversations
• LEAN
• Six Sigma
• Speak-up without fear
• Communication openness
• Shared behavior
expectations / goals
• Fair and just response to
errors
Culture
≠
55. Safety in Surgery
55
Processes
• Time out
• Stop Sign
• Site Marking
• Universal protocol
• SBAR
• Crucial Conversations
• LEAN
• Six Sigma
Culture
• Speak-up without fear
• Communication openness
• Shared behavior
expectations / goals
• Fair and just response to
errors
56. Safety in Surgery
56
Processes
• Time out
• Stop Sign
• Site Marking
• Universal protocol
• SBAR
• Crucial Conversations
• LEAN
• Six Sigma
Culture
• Speak-up without fear
• Communication openness
• Shared behavior
expectations / goals
• Fair and just response to
errors
• Trust
• How We Manage Errors
57. N o N o N o
Y e s
Y e s
N o Y e s
N o
Y e s
Y e s
Y e s
N o
N o
N o
Y e s
Y e s
N o
D im in is h in g
c u lp a b ilit y
D e c is io n T r e e f o r D e t e r m in in g C u lp a b ilit y o f U n s a f e A c t s
S a b o t a g e ,
m a le v o le n t
d a m a g e ,
s u ic id e , e t c .
S u b s t a n c e
a b u s e
w it h o u t
m it ig a t io n
S u b s t a n c e
a b u s e w it h
m it ig a t io n
P o s s ib le
r e c k le s s
v io la t io n
S y s t e m -
in d u c e d
v io la t io n
P o s s ib le
n e g lig e n t
e r r o r
S y s t e m -
in d u c e d
e r r o r
B la m e le s s
e r r o r
B la m e le s s
e r r o r b u t
c o r r e c t iv e
t r a in in g ,
c o u n s e lin g
n e e d e d
W e r e t h e
a c t io n s a s
in t e n d e d ?
U n a u t h o r iz e d
s u b s t a n c e ?
K n o w in g ly
v io la t e s a f e
o p e r a t in g
p r o c e d u r e s ?
P a s s
s u b s t it u t io n
t e s t ?
Y e s
H is t o r y
o f u n s a f e
a c t s ?
W e r e t h e
c o n s e q u e n c e s
a s in t e n d e d ?
M e d ic a l
c o n d it io n ?
W e r e p r o c e d u r e s
a v a ila b le ,
w o r k a b le ,
in t e llig ib le a n d
c o r r e c t ?
D e f ic ie n c ie s in
t r a in in g &
s e le c t io n o r
in e x p e r ie n c e ?
Reason, J., Managing the Risks of Organizational Accidents
Reason, J: Managing the Risk of
Organizational Accidents
58. Safety in Surgery
58
Processes
• Time out
• Stop Sign
• Site Marking
• Universal protocol
• SBAR
• Crucial Conversations
• LEAN
• Six Sigma
• Commitment Patient &
Colleagues
• Humility - Errors Inevitable
• Metacognition – Error
Prevention & Mitigation
Culture
60. Hazards of Leading of Change
60
“And one should bear in mind that there is nothing more difficult to
execute, nor more dubious of success, nor more dangerous to administer
than to introduce a new order to things; for he who introduces it has all
those who profit from the old order as his enemies; and he has only
lukewarm allies in all those who might profit from the new. ”
from Niccolo Machiavelli's "The Prince"
Editor's Notes
Our goals when deliver healthcare should be to provide the right care, to the right patient, at the right time. It is critical that we do that will maintaining or increasing the value of the healthcare we deliver. In doing this variability is the enemy.
Our goals when deliver healthcare should be to provide the right care, to the right patient, at the right time. It is critical that we do that will maintaining or increasing the value of the healthcare we deliver. In doing this variability is the enemy.
Our goals when deliver healthcare should be to provide the right care, to the right patient, at the right time. It is critical that we do that will maintaining or increasing the value of the healthcare we deliver. In doing this variability is the enemy.
Our goals when deliver healthcare should be to provide the right care, to the right patient, at the right time. It is critical that we do that will maintaining or increasing the value of the healthcare we deliver. In doing this variability is the enemy.