The document discusses quality and safety in global surgery. It notes that around 8.2% of patient records in developing countries show adverse events, 83% of which are preventable and 30% associated with death. Checklist implementation in surgery across 8 countries, including India and Tanzania, reduced mortality by nearly half and complications by a third. Lifebox is a nonprofit working to address unsafe surgery globally by providing equipment and training, including introducing safety checks in low and middle-income countries.

1. Quality and Safety
in Global Surgery
Scale, Science and Solutions
Dr Ed Fitzgerald
@DrEdFitzgerald

2. Background | Who am I?!
• Background in General Surgery
• Global Health Exec @ KPMG
• Co-founder of GlobalSurg
Lifebox Honorary Clinical Advisor:
• Surgical safety & WHO checklist
• Implementation science
• Patient safety training
LMIC experience working in:
• Rwanda
• Republic of Congo
• Madagascar
• Ethiopia
• Cambodia
• Honduras

3. “We’ve failed to view delivery of health care as a science.
The tasks of medical science fall into three buckets:
One is understanding disease biology
One is finding effective therapies
And one is ensuring those therapies are delivered effectively
That third bucket has been almost totally ignored by research
funders, government, and academia.
It’s viewed as the art of medicine.”
Peter J. Pronovost
Intensive care specialist physician
Johns Hopkins

4. What is high quality
healthcare?
“The degree to which
health care services for
individuals and populations
increase the likelihood of
desired health outcomes”
Agency for Healthcare Research and Quality (AHRQ)

5. CHARACTERISTIC DEFINITION
1. Safe Avoiding injuries to patients from the care that is intended to
help them
2. Effective Providing evidence-based services to all who could benefit and
avoiding those not likely to benefit (under use and over use)
3. Patient-centered Providing care that is respectful or and responsive to individual
patient preferences, needs and values, and ensuring these
guide clinical decisions
4. Timely Reducing waits and delays for both those who receive and
deliver care
5. Efficient Avoiding waste, including equipment, supplies, energy and
ideas
6. Equitable Providing care that does not vary in quality because of
personal characteristics such as gender, ethnicity, geographic
location and socioeconomic status
What are the characteristics of
high quality healthcare?
CHARACTERISTIC DEFINITION
1. Safe Avoiding injuries to patients from the care that is intended to
help them
2. Effective Providing evidence-based services to all who could benefit and
avoiding those not likely to benefit (under use and over use)
3. Patient-centered Providing care that is respectful or and responsive to individual
patient preferences, needs and values, and ensuring these
guide clinical decisions
4. Timely Reducing waits and delays for both those who receive and
deliver care
5. Efficient Avoiding waste, including equipment, supplies, energy and
ideas
6. Equitable Providing care that does not vary in quality because of
personal characteristics such as gender, ethnicity, geographic
location and socioeconomic status
Institute for Healthcare Improvement

7. For safety events in LMIC, what is the:
1. Proportion of adverse patient events?
2. Proportion that were preventable?
3. Proportion that were associated with death?
Safety: Understanding the Scale

8. Wilson et al BMJ study reviewed 8 developing countries:
– 8.2% (2.5-18.4%) of records showed an adverse event
– 83% were judged preventable
– 30% were associated with death of the patient
– 34% were therapeutic errors in non-complex situations
Safety: Understanding the Scale

9. Types of error in developing countries

10. Contributing factors in developing countries

11. Prevention strategies in developing countries

12. UK Scale of the Problem
• NHS England Never Events
NHS England: 1 in every 20,000 procedures, 4.6 million operations each year

13. 13
Country Year Anaesthesia mortality
United Kingdom 1985 1:187,000
Netherlands 1997 1:124,000
Zambia 1987 1:1,925
Malawi 2000 1:504
Zimbabwe 2001 1:482
Togo 2005 1:133
Benin 2010 1:150 (paediatric)
Cooper et al Anesthesiology 2002 97: 1609 -17
Walker, Wilson Lancet 2008 371: 968-9
Anaesthetic Context

15. GlobalSurg Collaborative

20. Material context:
physical environment, equipment and supplies

21. Relational context: teamwork and hierarchy

22. • 30% of the participants said errors occur frequently
• Inadequate data to measure the scale of medical error and its
impact on the healthcare
• No wide knowledge of patient safety and healthcare quality

24. “Attributing every medical adverse event in the course of
treatment as “God’s Will” and the saying “It’s God’s Time”
for every death among most African people has also
become a great impediment to curbing clinical negligence
in our environment.”

25. What are the Solutions?
1. Investment in surgical care
2. Investment in training and workforce
3. Investment in technology and infrastructure
4. Improving the quality of existing services
(including patient safety, audit and baselines)

27. Headline results
• WHO funded patient safety initiative
• Pre/post checklist implementation study
• 8 countries worldwide (incl India, Philippines, Tanzania)
• 3,733 pre and 3,955 post implementation patients enrolled
• Reduced mortality by nearly half
1.5% to 0.8%
• Reduced complications by a third
11% to 7%

28. • Post checklist implementation,
overall complication rate fell
from 21.5% to 8.8% (P< 0.001)
• Infectious and non-infectious
complications decreased
significantly

30. “It is not the act of ticking off a checklist that
reduces complications, but performance of
the actions it calls for.”
Lucian L. Leape
The Checklist Conundrum

31. Human behaviour flows from three
main sources:
Desire, emotion, and knowledge.
Plato

37. www.lifebox.org

38. Who are Lifebox?
• Global surgical safety NGO charity
• Promoting safer perioperative surgical practice
• Working in low- and middle-income settings
• World Federation of Societies of
Anaesthesiologists
• Harvard School of Public Health
• Brigham and Women’s Hospital
• AAGBI

39. 39
Who are Lifebox?
• Founded in 2011, Lifebox is a registered charity working to address the
growing global crisis of unsafe surgery through distribution of equipment
and training, and introduction of life-saving basic safety checks in LMICs
• Lifebox reach:
o Distributed >14,000 pulse oximeters to ORs in >100 countries
o Fully met the OR need for pulse oximeters in 27 countries
• Lifebox pulse oximeter:
o Low-cost, high-quality, medical specification oximeter
o USD$250 per oximeter and USD$25 per probe

42. Ethiopia

43. • https://vimeo.com/194067120

44. Reflections for you to finish
1
2
3
Start big to work small
Change is a long-term endeavour
Improving safety is a universal intervention

45. Questions?
@DrEdFitzgerald
jeffitzgerald@gmail.com
Thank you!