LECTURE maintenance management is important 1.pptx
Risk management in surgery (bailey and love).pptx
1. Risk management in surgery
Dr Saujanya Jung Pandey
General surgery
Moderator- Dr Mahesh mani adhikari
2. Introduction
• Critical aspect of ensuring patient safety and optimizing outcomes
• systematic identification, assessment, and mitigation of potential risks
and complications
3. • aim to minimize adverse events, improve patient care, and enhance
the overall quality
• Medicine can never be risk free
• ‘primum non nocere’- do no harm
4. Prevalence of adverse healthcare events
• In US, over 250,000 patients/ year
• Over 100,000 patients will die
• A systemic analysis review found an annual incidence of 10%, among
which 50% were preventable.
5. Some definitions
Patient safety incidents
• An Adverse event- an incident which results in harm to the patient
• A near miss- an incident which could have resulted in unwanted harm
but did not
• A no-harm event-an incident that occurs and reaches the patient but
results in no injury.
6. Factors that contribute to patient safety
incidents
• Human factors
• System failures
• Medical complexities
7. Human factors
• Inadequate patient assessment; delays or errors in diagnosis
• Failure to use or interpret appropriate tests
• Error in performance of an operation, treatment or test
• Inadequate monitoring or follow-up of treatment
• Deficiencies in training or experience
• Fatigue, overwork, time pressures
• Personal or psychological factors (e.g. depression or drug abuse)
• Patient or working environment variation
• Lack of recognition of the dangers of medical errors
8. System failures
• Poor communication between healthcare providers
• Inadequate staffing levels
• Disconnected reporting systems or over-reliance on automated systems
• Lack of coordination at handovers
• Drug similarities
• Environment design, infrastructure
• Equipment failure owing to lack of parts or skilled operators
• Cost-cutting measures by hospitals
• Poor governance structures and inadequate systems to report and review
patient safety incidents
9. Medical complexities
• Advanced and new technologies
• Potent drugs, their side effects and interactions
• Working environments – intensive care, operating theatres
10. Understanding patient safety incidences
• helps to anticipate situations that lead to errors and highlights areas
for prevention
• can be viewed in two ways – from a person approach or from a
system approach
11. The person approach
• Humans are falliable
• Errors can occur due to -doing the wrong thing – errors of
commission; failure to act – errors of omission; or errors of execution
– doing the right thing incorrectly
• assessed by professional appraisal processes and clinical audit
12. The system approach
• Health systems add complex organizational structures to human
fallibility, thus substantially increasing the potential for errors
• Majority of near misses or adverse events are due to system factors
• Based on error models-
• Heinrichs safety pyramid
• Swiss cheese model
13. • Heinrichs safety pyramid
• 1931
• Unsafe acts or near misses lead to
minor injuries and over time to a major
injury
• It is important to report near misses as
well as adverse events to ensure that
defences are built and sustained
14. Swiss cheese model
• explains the consequences of
multiple errors that result in
harm, analogous to the holes in a
Swiss cheese, which if aligned
create a defect that has adverse
consequences.
15. Surgical errors
• Surgery is one of the most complex health intervention to deliver.
More than 100 million people worldwide require surgical treatment
every year for different reasons
16. Cuschieri describes coal-face errors as :
• diagnostic and management errors;
• resuscitation errors;
• prophylaxis errors;
• prescription/parenteral administration errors;
• situation awareness, identification and teamwork errors;
• technical and operative errors.
17. Situation awareness- identifying teamwork
errors
• wrong patient in the OT;
• surgery on the wrong side or site;
• wrong procedure;
• failure to communicate changes in the patient’s condition;
• disagreements about proceeding;
• retained instruments or swabs
18.
19. Technical and operative errors
• cognitive errors of judgement
• procedural
• Executional
• misinterpretation of anatomy/pathology
• misuse of instrumentation
• missed iatrogenic injury
20. Strategies for patient safety
International
• Global and regional initiatives from WHO since 2009
• WHO’s Second Global Patient Safety Challenge, Safe Surgery Saves
Lives
• Surgical checklist
21. In resource rich countries-
• regulatory systems
• national/statutory policies;
• standard setting by professional bodies;
• national clinical audits and quality improvement programmes;
• statutory reporting of adverse events.
22. Low and middle income countries
• They face issue requiring different strategies
• issues are more acute due to lack of resources, parts and necessary
skills
• Lack of monitoring in training programme, lack of accountability,
corruption and malpractice
23. Institutional or hospital
• Seek opportunities for certification and accreditation
• Engage with available national and international audits
• Seek collaboration
• clinical governance, leadership and team-building programmes and
foster teamworking
24. Checklists
• accepted as standard safety protocols
• Use of perioperative surgical safety checklist in 8 hospitals ;
• associated with reduction in perioperative mortality -1.5% to 0.7%
and major inpatient complications- 11.0% to 7.0%
25.
26. WHO surgical safety checklist
• tool by WHO to improve communication and teamwork in the OT and
enhance patient safety
• To be used before, during, and after surgery to help surgical teams
reduce the risk of errors, complications, and adverse events.
• first introduced in 2008 - WHO's Safe Surgery Saves Lives initiative.
27. Sign In (Before Anesthesia Induction):
• Confirm patient identity, procedure, and site.
• Mark the surgical site if applicable.
• Ensure availability of essential equipment and resources.
• Review patient allergies and specific concerns.
28. Time Out (Before Incision):
• Confirm patient identity, procedure, and site again.
• Confirm the surgical team's understanding of the procedure and key
steps.
• Address any critical concerns or potential issues.
29. Sign Out (Before the Patient Leaves the Operating Room):
• Confirm the completion of all planned steps of the procedure.
• Verify instrument, sponge, and needle counts.
• Review key concerns and next steps for postoperative care
30. • The WHO checklist should be completed for every patient
• Appropriate Antibiotic prophylaxis, VTE prophylaxis, careful
positioning, temperature, glycemic and infection control
• Optimize lighting, ventilation , humidity and temperature
• Diathermy and torniquets should be used cautiously
• Theatre etiquettes to minimize crossinfection
31. Right surgeon, right place, right time:
• A surgeon of adequate training and experience
• trained surgeons require updating in current techniques and training in new
one
• Right timing in case of emergencies
32. • Standardization of process-
• Pre-op investigations
• Optimization of co morbidity
• DVT prophylaxis
• Antibiotic prophylaxis
• Management of Pt requiring emergency surgery
33. Communicating openly with patients and
their carers and obtaining consent
• The condition and the reasons why it warrants surgery.
• The type of surgery proposed and how it might correct the condition.
• The anticipated prognosis and expected side effects of the proposed
surgery.
• The unexpected hazards of the proposed surgery.
• Any alternative and potentially successful treatments other than the
proposed surgery.
• The consequences of no treatment at all.
34. Professional behavior and maintaining fitness
to practice
Fitness to work or practice- competence
Credentialing
35. Reporting adverse events and near misses
• Unreported- fear of blame and potential for litigations
• Data from these episodes should be learnt from in institutional level and
uploaded to national databases
• Complains from patient highlights a problem and can help reduce adverse
events
36. Prescribing safely
Common medication errors include:
• poor assessment or inadequate knowledge of patients and their
clinical conditions;
• inadequate knowledge of the medications;
• dosage calculation errors;
• illegible handwriting;
• Confusion in name or mixing up medications
it helps to anticipate situations that are likely to lead to errors and highlights areas where preventative action can be taken
can be viewed in two ways – from a person approach or from a system approach
Cuschieri describes coal-face errors as those that can potentially be committed by surgeons during the care of their patients and include
cognitive errors of judgement, such as late conversion of a difcult laparoscopic procedure into an open one;
procedural, when the steps of an operation are not followed or are omitted;
executional, when, for example, too much force is used, which may result in damage that may or may not have consequences;
misinterpretation of anatomy/pathology, which is compounded by minimal access surgery with the limitations of a two-dimensional image;
misuse of instrumentation, such as with energised dissection modalities (e.g. diathermy);
missed iatrogenic injury either at the time of surgery or diagnosed late.
Surgical checklists , an effective strategy ,has been shown to improve surgical outcomes in both low- and middle-income countries and in wealthier countries.
regulatory systems for licensing of physicians and healthcare institutions;
national/statutory policies for patient safety;
standard setting by surgical professional bodies;
national clinical audits and quality improvement programmes;
statutory reporting of adverse events.
They face issue requiring different strategies
Patient safety issues are more acute due to lack of resources, parts and necessary skills
Lack of monitoring in training programme, lack of accountability, corruption and malpractice
Seek opportunities for certification and accreditation from national and international healthcare quality improvement organisations
Engage with available national and international audits
Seek collaboration with recognised training bodies and quality improvement organisations
Hospitals or institutions that offer the greatest patient safety systems develop clinical governance, leadership and team-building programmes and foster teamworking
accepted as standard safety protocols
Use of perioperative surgical safety checklist in 8 hospitals around the world was associated with a reduction in perioperative mortality from 1.5% to 0.7% and major inpatient complications from 11.0% before to 7.0% after the introduction of the checklist
Designed to be used before, during, and after surgery to help surgical teams reduce the risk of errors, complications, and adverse events.
It was first introduced in 2008 as part of the WHO's Safe Surgery Saves Lives initiative.
The WHO checklist should be completed for every patient coming to the theatre
Appropriate Antibiotic prophylaxis, VTE prophylaxis, careful positioning, temperature, glycemic and infection control
The OT should be optimized with regard to lighting, ventilation , humidity and temperature
Diathermy and torniquets should be used cautiously
Theatre etiquettes including scrubbing, prepping and draping and personnel movements to minimize crossinfection
Go unreported for fear of blame and potential for litigations
Data collected from these episodes should be learnt from in institutional level and uploaded to national databases
Complains from patient often highlights a problem and can provide opportunities to reduce adverse events
