PRINCIPLES OF SURGERY: PATIENT SAFETY

life, despoiling of the environment, or some other

situation that gives rise to the sense of dread.
- are complex, in that they have large numbers of highly
inter-dependent subsystems with many possible
combinations that are nonlinear and poorly understood.
- are tightly couple, so that nay perturbation in the
system is transmitted rapidly between subsystems with
little attenuation.
COMMON CHARACTERISTICS
1. People are supportive of one another
2. People trust one another
3. People have friendly, open relationships emphasizing
credibility and attentiveness.
4. The work environment is resilient and emphasizes
creativitu and goal achievement, providinf strong
feelings of credibility and personal trust.
DONABEDIAN MODEL (CONCEPT)
TYPES OF IMPROVEMENTS:
1. STRUCTURE
- refers to the physical anf organizational tools,
equiomen, and policies that improve safety.
- structural measures ask, Do the right tool,
equioment, and policies exist?
2. PROCESS
- is the application of these tools. Equipment, and
policies/ procedures to patients (good practices and
evidence-based medicine)
- process measures ask. Are the right tools, policies,
and equipment being used?
3. OUTCOME
- is the result on patients.

PATIENT SAFETY
HIGH RELIABILITY ORGANIZATION THEORY
High risk industries an=d organizations that achieved low
accident and error rates
HIGH RISK SYSTEMS:
- Have the potential to create a catastrophe, loosely
defined as an event leading to loss of human or anaimal

- outcome measures asks, how often are the patients

harmed?
In this model, structure (how care is organized) plus
process (what we do) influences patient outcomes (the
results achieved
CREATING A CULTURE OF SAFETY
- an acknowledgement of the high risk, error prone
nature of an organizations activities

- a nonpunitive environment where individuals are able

to report errors or close calls without feat of punishment
or retaliation
- an expectation of collaboration across ranks to seek
solutions to vulnerabilities

***Engineered defensive systems include automatic

shut-downs (alarms, forcing functions, physical barriers).
Other defensive mechanisms are dependent on people
such as pilots, surgeons, anaesthetists, control room
operators. Procedures and rules are also defensive
layers

- a willingness on the part of the organization to direct

resources to address safety concerns
WHY PATIENT SAFETY?
HARM TO PATIENT
Increased hospital stay
Permanent injury
Death

BLAME CULTURE RATIONALE FOR MANAGING HUMAN

ERROR
SYSTEM FAILURE AND ERROR

Human actions are almost always constrained and

governed by factors beyond an individuals
immediate control. (A medical student working in a
surgical ward is constrained by the hospitals
management of the theatres.)

People cannot easily avoid those actions that they

did not intend to perform. (A medical student may
not have intended to obtain consent from a patient
for an operation but was unaware of the rules in
relation to informed consent.)

Errors have multiple causes: personal, taskrelated,

situational and organizational factors. (If a medical
student entered the theatre without correct
scrubbing it may be because the student was never
shown the correct way, has seen others not comply
with scrubbing guidelines, the cleaning agent had
run out, there was an emergency that the student
wanted to see and there was no time, etc.)

Organizational structure
Multiple factors
Workplace conditions

*The viton O-ring seals failed in the solid rocket boosters

shortly after launch. The Rogers Commission also found
that other flaws in shuttle design and poor
communication may have also contributed to the crash.
**For nearly a year before the Challengers last mission
the engineers were discussing a design flaw in the field
joints. Efforts were made to redesign a solution to the
problem but before each mission, both NASA and
Thiokol officials (a company that designed and built the
boosters) certified the solid rocket boosters were safe to
fly. (See Challenger: a major malfunction by Malcolm
McConnell, Simon & Schuster, 19877. Challenger had
previously flown nine missions before the fatal crash.

Within a skilled, experienced and largely

wellintentioned workforce, situations are more
amenable to improvement than people. (If staff
were prevented from entering theatres until
appropriate cleaning techniques were followed,
then the risk of infection would be diminished.)
VIOLATIONS

ROUTINE VIOLATION
- Doctors who fail to wash their hands in between
patients because they feel they are too busy is an
example of a routine violation.
- Reason stated that these violations are common and
often tolerated. Other examples in health care would be
inadequate handovers, not following a protocol and not
attending on-call requests.
OPTIMIZING VIOLATION
- Doctors who let a medical student perform a
procedure unsupervised because they are with their
private patients is an example of an optimizing violation.
- This category involves a person being motivated by
personal goals such as greed or thrills from risk taking,
performing experimental treatments and performing
unnecessary procedures.
NECESSARY VIOLATION
- Nurses and doctors who knowingly miss out important
steps in medication dispensing because of time
constraints and the number of patients to be seen is an
example of a necessary violation.
- A person who deliberately does something they know
to be dangerous or harmful does not necessarily intend
a bad outcome but poor understanding of professional
obligations and a weak infrastructure for managing
unprofessional behaviour in hospitals provide fertile
ground for aberrant behaviour to flourish.
PATIENT SAFETY

Training to become an excellent team member starts in

medical school. Learning how to substitute roles and
appreciate the others perspective is central to effective
teamwork.
PATIENT SAFETY DEFINITION
(EMANUEL ET AL)
A discipline in the health-care sector that applies safety
science methods towards the goal of achieving a
trustworthy system of health-care delivery.
Patient safety is also an attribute of health-care systems;
it minimizes the incidence and impact of, and maximizes
recovery from adverse events.
PATIENT SAFETY FOUR DOMAINS
(EMANUEL ET AL)
1. those who work in health care
2. those who receive health care or have a stake in its
availability
3. the infrastructure of systems for therapeutic
interventions (health-care delivery processes)
4. the methods for feedback and continuous
improvement.
5 WHYS
- Statement: The nurse gave the wrong drug.
Why?
- Statement: Because she misheard the name of the
drug ordered by the doctor.
Why?
- Statement: Because the doctor was tired and it was in
the middle of the night and the nurse did not want to
ask him to repeat the name.
Why?
- Because she knew that he was known to have a temper
and would shout at her.
Why?
- Because he was very tired and had been operating for
the last 16 hours
Why?
- Because

Reason, a cognitive psychologist, emphasized that

practitioners should make a habit of sharing their
experiences of adverse events.

SITUATION

Being an effective team member has risen in importance

as we better understand the role of accurate and timely
communication in patient safety.

What is going on with the patient?

I am calling about Mrs Joseph in room 251, Chief
complaint is shortness of breath of new onset

COMMUNICATION BETWEEN HEALTH PROF SBAR

BACKGROUND

HANDOVER OR HANDOFF

What is the clinical background or context?

Patient is 62 y/o female post-op day one from
abdominal surgery. No prior history of cardiac or lung
disease.

INTRODUC
-TION

Introduce yourself, your role and

job and the name of the patienr

PATIENT

Name, identifiers, age, sex,

location

ASSESSMENT

Present chief complaint, v/s,

symptoms and diagnosis

SITUATION

Current status/ circumstances,

including code status, level of
(un)certainty, recent changes and
response treatmet

SAFETY
CONCERNS

Critical lab values/reports,

socioeconomic factors, allergies
and alerts(falls, isolation and so on)

BACKGROUND

Co-morbidities, previos episodes,

current medications and family
history

Helps team members anticipate the next steps

ACTIONS

Directs responsibility to a specific individual

responsible for carrying out the task

What actions were talen or

required? Provide brief rationale

TIMING

Level of urgency and explicit timing

and prioritization of actions

OWNERSHIP

Who is responsible (person/team).

Including patient/family.

NEXT

What will happen next?

Anticipated changes?
What is the plan?
Are there contingency plans?

ASSESSMENT
What do I thing the problem is?
Breath sounds are decreased in the right side with
acknowledgemnt of pain. Would like to rule out
pneumothorax.
RECOMMENDATION
What would I do to correct it?
I feel strongly the patient should be assessed now. Are
you available to come in?
CALL-OUT IMPORTANT/CRITICAL INFO
(e.g. ACLS)
During all temas simultaneously during emergent
situations

Leader: Airway status?

Resident: Clear
Leader: Breath sounds?
Resident: Breath sounds decreased on right
Leader: Blood pressure?
Resident: BP is 90/60
CHECK BACK
- a simple technique for ensuring information conveyed
by the sender is understood by the receiver, as
intended:
Sender initiates message
Receiver accepts message and provides
feedback
Sender double-checks to ensure the message is
understood
Doctor: Give 25mg Benadryl IV push.
Nurse: 25mg Benadeyl IV push?
Doctore: Thats correct!

The

THREE MAIN CAUSES OF ADVERSE EVENTS IN SURGICAL

CARE
Poor infection control methods
Inadequate patient management
Failure by health care providers to communicate
effectively before, during and after operative
procedures
POOR INFECTION CONTROL METHODS
Pophylactic antibiotic
Risks of transmission health workers minimizes
risks of cross-infection
- handwashing
- clothing

EXAMPLE OCCASION
INADEQUATE PATIENT MANAGEMENT
(LATENT FACTORS)
Inadequate
implementation of
protocol or guideline
Poor teamwork
Inadequate training &
preparationof staff
Lack of evidence-based
practice
overwork

Poor leadership

Conflict between different

department and the org
Inadequate resources
Poor work culture
Lack of system for
managing performance

Avoid delays in treatment

Practicing outside an area
of expertise (failure to
consult, refer, seek
assistance, transfer)

Failure to employ indicated

tests
Failure to act upon the
results of findings or test

FAILURE BY HEALTH CARE PROVIDERS TO COMMUNICATE

EFFECTIVELY
TYPE OF
FAILURE
OCCASION
CONTENT
AUDIENCE
PURPOSE

NOTE: since antibiotics are optimally given within 30

minutes of incision, the timing of this inquiry is ineffective
both as a prompt and as a safety redundancy measure.
EXAMPLE AUDIENCE

INADEQUATE PAATIENT MANAGEMENT ERRORS

Communication failures:
- info is provided too late to
be effective
- info is inconsistent or
inaccurate
- key people are excluded
from the info
- there are unresolved issues
in the team
Failure to keep precautions
to prevent accidental injury
Wound infections, other
wound problems, tech
problems & bleeding
Failure to tale adequate
history or PE

The staff surgeon asks the anaesthetist whether the

antibiotics have been administered. At this point, the
procedure has been under way for over an hour.

DEFINITION
Problems in the situation context of
the communication event
Insufficiency or inaccuracy apparent in
the information being transferred
Gaps in the composition of the group
engaged in the communication
Communication events in which
purpose is unclear, not achieved or
inappropriate

The burse and the anaesthetist discuss how the patient

should be positioned for surgery without the
participation of a surgical representative.
NOTE: surgeons have particular positioning needs so they
should be participants in this discussion. Decisions made
in the absence of the surgeon may lead to the need for
re-positioning
EXAMPLE PURPOSE
During a living donor liver resection, the nurses discuss
whether ice is needed in the basin they are preparing for
the liver. Neither knows. No further discussion ensues.
NOTE: The purpose of this communication to findout if
ice is required

The ultimate goal of the WHO Surgical

Safety checklist and of this manual is
to help ensure that teams consistently
follow a few critical safety steps and
thereby minimize the most common and
avoidable risks endangering the lives and
well-being of surgical patients

FRAMEWORK FOR MANAGING CONFLICTS IN MEDICAL

SITUATIONS
AREA OF
ATTRIBUTE
EXAMPLE
OLD WAY

Medical hierarchies:
handwashing
Doctor does not clean hands between
patients
Student says nothing and conforms to
inadequate technique. Imitate senior
doctor

AREA OR
ATTRIBUTE
EXAMPLE

OLD WAY

Paternalism:
Consent
Student asked to get consent from a
patient for surgical procedure the student
has never heard of before
Accept task. Do not let senior staff know
level of ignorance about procedure. Talk
to the patient about the procedure in a
vague and superficial way so as to get the
patients signature on the consent form.

NEW WAY

NEW WAY

1. Seek clarification of the correct technique for

handwaashing with the doctor or other senior person.

1. Decline the task and suggest that a doctor with some

familiarity with the procedure would be more
appropriate for this task.
2. Accept the task, but explain you know little about the
procedure so will need some teaching about it first and
request that one of the doctors comes along to help/
supervise.

2. Say nothing but use safe hand washing techniques

3. Say something in respectful manner to the doctor
concerned and continue to use safe handwashing
techniques.
AREA OR
ATTRIBUTE
EXAMPLE

OLD WAY

Medical Heirarchies:
Site of surgery
Surgeon does not participate in checking
the correct site for surgery or verifying the
correct patient.
The surgeon is resentful of the
preoperative checking protocol, believing
it to be a waste of time, and pressures the
rest of the team to hurry up.
Adopt the approach if the surgeon and do
not participate in checking decide that
checking is too menial a task for a doctor
anyway

AREA OR
ATTRIBUTE
EXAMPLE

OLD WAY

Infallibility of doctors:
Hours of Work
A junior doctor on the ward announces
with pride that they have been at work for
the last 36 hours
Admire the doctor for their stamina and
commitment to their work

NEW WAY
1. Ask the doctor how they feel and whether it is wise or
even responsible to still be working
2. Ask the doctor when they are due to finish and how
they are going to get home? Are they safe to even drive
a car?

NEW WAY
1. Actively help the rest of the team to complete the
checking protocol
AREA OR
ATTRIBUTE
EXAMPLE

OLD WAY

Medical Heirarchies:
Medication
Student knows that a patient has a known
serious allergy to penicillin and observes a
senior doctor prescribe penicillin
Say nothing for fear of being seen to
disagree with a senior doctors decision.
Presume that the doctor must kniw what
they are doing anyway

3. Make some helpful suggestions: Is there someone

who can carry your pager so you can go home and get
some rest or I didnt think it was allowed for doctors to
work such long hours, you should complain about your
roster.
AREA OR
ATTRIBUTE
EXAMPLE

OLD WAY

Team work:
My team is the medical team
Students and junior doctors identify only
other doctors as being part of their team
The doctors in the word do their rounds
without a member of the nursing staff
present.
change behaviour to reflect that of the
rest of the doctors and identify only with
the medical members of the team

NEW WAY

Algorithm for navigating the process of informed consent.

1. Be mindful that the team from a patients perspective

is everyone who cares for and treats the patient
nurses, ward staff, allied health, including the patient
and their family members
2. Always suggest including other members of the health
care team in conversations and discussions about a
patients care and treatment.
3. Acknowledge and maximize the benefit of an
interprofessional team.
KEY POINTS
1. Patient harm due to medical mistakes can be
catastrophic and, in some cases, result in high-profile
consequences not only for the patient, but also for the
surgeon and institution
2. Patient safety is a science that promotes the sue of
evidence based medicine and common sense
improvements in an attempt to minimize the impact of
human error on the routine delivery of services.
3. The structure-process-outcome framework within the
context of an organizations culture helps to clarify how
risks and hazards embedded within the organizations
structure may potentially lead to error and injure or
harm patients.
4. Poor communication contributes to approximately
60% of the sentinel events reported to The Joint
Commission
5. Operating room briefings are team discussions of
critical issues and potential hazards that can improve the
safety of the operation and have been shown to improve
operating room culture and decrease operating room
delays.
6. National Quality Forum surgical never events include
retained surgical items, wring-site surgery, and death on
the day of surgery of a normal healthy patient (American
Society of Anesthesiologists Class 1)
7. PATIENT RAPPORT is the most important determinant
of malpractice claims against a surgeon

THE CODE OF PROFESSIONAL CONDUCT continues:

As Fellows of the American College of Surgeons, we
treasure the trust that our patients have placed in us
because trust is integral to the practice of surgery.
During the continuum of pre-, intra-, and postoperative
care, we accept the following responsibilities:

Serve as effective advocates of our patients

needs
Disclose therapeutic options, including their risks
and benefits
Disclose and resolve any conflict of interest that
might influence decisions regarding care
Be sensitive and respectful of patients,
understanding their vulnerability during the
perioperative period
Fully disclose adverse events and medical errors
Acknowledge patients psychological, social,
cultural, and spiritual needs
Encompass within our surgical care the special
needs of terminally ill patients
Acknowledge and support the needs of patients
families
Respect the knowledge, dignity, and perspective
of other health care professionals

Look for something positive in each day, even if some days you have to look a little harder.

rjnsawey

^_^