BOMBAY HOSPITAL, INDORE

PROJECT REPORT ON:

“SURGICAL SAFETY AUDIT CHECKLIST”

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 INTRODUCTION TO BOMBAY HOSPITAL

Bombay Hospital is a trust

hospital in Indore, India. It
was found in Mumbai in
1951 by R.D Birla. It was
founded in Indore in 2003.
Bombay Hospital is a
private hospital in Mumbai,
India. Bombay Hospital
Indore is its branch located
at Ring road Indore It has
600 beds (presently
running 315 beds), 74 of
which are in the critical care and recovery area. It offers tertiary healthcare
facilities; it also has 7 Operation Theatres and offering services for all super
specialties to the: -

• Neurosurgery

• Neurology

• Cardiology

• Gastroenterology

• Nephrology

• Onco-surgery

•Specialties like General Medicine, Paediatrics, General and Laparoscopic

surgery, Orthopaedics and joint replacement.

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 VISION
“To render the same level of service to the poor that the rich will get in a good
hospital.”

MISSION
“Bombay Hospital shall provide the best possible the best possible medical
treatment, delivered most efficiently, in the shortest possible time, at
minimum cost, to all sections of the society, irrespective of caste, creed or
religion.”

MOTTO
A Patient is the most important person in our Hospital. He is not an
interruption to our work. He is the purpose of it. He is not an outsider in our
Hospital, he is part of it. We are not doing him a favour by serving him, he is
doing us a favour by giving us an opportunity to do so. Bombay Hospital is one
of the renowned hospital of central India. Located at Ring Road of Indore,
Bombay hospital is very much accessible to all parts of the city, state as well as
nation. The excellent service provided by Bombay Hospital has been
recognized by whole of the country.

PREFACE
Shri Rameshwardas ji Birla, in whose memory the endowment has been setup,
was a leading Industrialist and philanthropist who dedicated his life to medical,
social, cultural, educational and religious activities all over India. He was the
pioneering spirit behind the Bombay Hospital and was the founder Chairman
of its Trust.

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 SERVICES OFFERED BY BOMBAY HOSPITAL

SCOPE OF SERVICES
1. Outpatient Services

2. Inpatient Services

3. Adult Intensive Care Services

4. Paediatric & Neonatal Intensive Care

5. High Dependency Care Services

6. Emergency Services

7. Operation Theatre Services.

DIAGNOSITICS
1. Blood Transfusion Service

2. Cath Lab

3. ECG, Echo/Stress & Holter

4. EEG & EMG

5. Histopathology

6. MRI & CT Scan

7. Pathology

8. Pulmonary Function Lab

9. Ultrasound

10. Urodynamic

11. X’RAY

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CLINICAL SERVICES
1. Cardiology

2. Cardiac surgery

3. Chest Medicine

4. Critical Care Medicine

5. Dermatology

6. ENT (Otorhinolaryngology)

7. Gastroenterology including GI Endoscopy

8. General Medicine

9. General Surgery

10. Gynaecology and Obstetrics including High Risk Obstetrics Care

11. Medical Oncology & Haematology

12. Nephrology (Haemo & Peritoneal Dialysis)

13. Neurology

14. Neurosurgery

15. Ophthalmology

16. Orthopaedics

17. Joint Replacement

18. Paediatrics & Neonatology

19. Plastic Surgery

20. Psychiatry

21. Surgical Oncology

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22. Urology including Renal Transplant

23. Anaesthesiology

RELATED SERVICES
1. Ambulance

2. Executive Heath Check-up

3. Housekeeping

4. Kitchen & Dietary Services

5. Laundry

6. Nursing

7. Physiotherapy

8. Security & Fire Safety

ROUND THE CLOCK

1. Admission

2. ECG & X-RAY

3. Path Lab

4. Pharmacy

HEATH LIBRARY
1. Heath Tips

2. Heath Education

3. Tests and Procedures

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ADMINISTRATIVE SERVICES
1. Medical Administration

2. Accounts & Finance

3. Marketing

4. TPA & Health Insurance Claims

5. Biomedical Engineering

6. Engineering Services

7. Human Resource

8. IT Department

9. Material Management

10. Medical Record Department

11. Quality Assurance Cell

SURGICAL
1. Cardiovascular & Thoracic Surgery

2. Ear/Nose/Throat (ENT)

3. General Surgery

4. Renal Transplant

5. Neurology

6. Obstetrics & Gynaecology Surgery

7. Ophthalmology

8. Orthopaedics

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9. Plastic Surgery

10. Surgical Oncology

11. Urology

12. Gastrointestinal, Laparoscopic & Hepato-Pancreatic-Biliary Surgery

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 OVERVIEW OF BOMBAY HOSPITAL
EAST WING

12th FLOOR DLUXE AND FIRST CLASS BEDS

11th FLOOR PRIVATE CORPORATE WARD

ARTIFICIAL KIDNEY UNIT/NICU/SEMI-

10th FLOOR
PRIVATE BEDS

9th FLOOR NURSE'S HOSTEL

8th FLOOR NURSE'S HOSTEL

7tH FLOOR GENRAL WARD

6th FLOOR COLLEGE OF NURSING

FEMALE GENRAL WARD, LABAROUR

5th FLOOR
ROOM

4th FLOOR ICU

3th FLOOR
MESS

2nd FLOOR RECOVERY ROOM

1st FLOOR ADMINISTRATION, OPD

OPD, CASUALTY, ADMISSION,

GROUND FLOOR
DISCHARGE, PHARMACY, PATHOLOGY

1st BASEMENT X-RAY, PHYSIOLOGY, BLOOD BANK

2nd BASEMENT STORE, LAUNDRY

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 WEST WING

12th FLOOR DELUXE ROOM, PRIVATE ROOM

11th FLOOR PRIVATE WARD

10th FLOOR SEMIPRIVATE WARD

9th FLOOR NURSE'S HOSTEL

8th FLOOR NURSE'S HOSTEL

7th FLOOR SEMI-PRIVATE WARD

6th FLOOR NURSING COLLEGE

5th FLOOR MALE GENERAL WARD

4th FLOOR CARDIAC ICU

3th FLOOR MESS

2nd FLOOR OT

1st FLOOR DIAGNOSTIC & CONSULTING ROOM

GROUND FLOOR HELP DESK, TEMPLE

1st BASEMENT CT SCAN, MRI

2nd BASEMENT LINEN DEPARTMENT

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 INTRODUCTION

In 2008 the World Health Organization (WHO) introduced a surgical

safety checklist applicable to all surgical teams to be used for every patient
undergoing a surgical procedure. This tool has been implemented around the
world, and encourages dialogue within multidisciplinary teams and the use of
routine safety checks to minimize harm to our patients.

History Of The WHO Surgical Safety Checklist

In 2002 the World Health Assembly urged countries to improve the safety of
health care and monitoring systems. They requested that the WHO set global
standards of care and provided support for countries to improve patient
safety. As a result, WHO Patient Safety was formed, and focussed its energy on
campaigns named Global Patient Safety Challenges. Following their first
challenge, ‘Clean Care is Safer Care’, WHO launched ‘Safe Surgery Saves Lives’
and led by Professor Atul Gawande, published WHO Guidelines for Safe
Surgery. This set out 10 essential objectives for safe surgery from which the
Surgical Safety Checklist was derived.

The aim of this ‘WHO checklist’ was to give teams a simple, efficient
set of priority checks to improve effective teamwork and communication and
encourage active consideration of patient safety for every operation
performed. WHO also wanted to ensure consistency in patient safety in
surgery and introduce (or maintain) a culture that values patient safety.

In a pilot study of the WHO checklist implementation, Professor

Gawande’s team prospectively observed over 3000 patients prior to the
introduction of the checklist and nearly 4000 patients after checklist
implementation, and measured the rate of surgical complication or mortality
up to 30 days after surgery or until discharge. The study included four hospitals
in low- and middle-income countries and four hospitals in high-income
countries and found the overall rate of death prior to introduction of the
checklist was 1.5% and after checklist implementation fell to 0.8%. Inpatient
complications were also reduced, from 11% pre checklist to 7% after the
checklist was introduced. As a measure of adherence to the checklist, they
identified 6 safety indicators, such as pre-incision antibiotics, swab counts and

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 routine anaesthetic checks, and saw an increase in performance of these from
34.2% pre checklist to 56.7% post checklist. It is interesting that even with only
56% completing these 6 indicators, significant reductions in complications and
death rates were seen. The checklist implementation team used team
introductions, briefings and debriefings as part of the safety routine, which has
also been formalised as part of the checklist strategy in the UK .

By September 2014, the WHO team had identified 4132 institutions who had
expressed an interest in using the checklist and 1790 institutions who were
actively using the checklist in at least one operating theatre. Seven years after 
introduction of the checklist, numerous studies have shown the benefit of the
checklist, but observers, audits and trials have also reported common barriers
to successful use of this patient safety tool. Key to successful implementation
across all cultures, economies and specialties seems to be engagement of the
whole team, through understanding the relevance and power of this tool in
their setting.

WHO Surgical Safety Checklist

The WHO Surgical Safety Checklist was developed after extensive consultation
aiming to decrease errors and adverse events, and increase teamwork and
communication in surgery. The 19-item checklist has gone on to show
significant reduction in both morbidity and mortality and is now used by a
majority of surgical providers around the world.

Constituent parts of the checklist

There are three phases to the checklist:

1. Sign in – before induction of anaesthesia, ideally with surgeon present, but

not essential, verbally verify, review with the patient when possible:
a. Patient identity
b. Procedure and site
c. Consent for surgery
d. Operative site is marked if appropriate (involving left or right distinction)

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 e. Pulse oximeter is on the patient and functioning
Review between anaesthetist and checklist coordinator:
f. Patient’s risk of blood loss. If >500ml in adults or >7ml/kg in children, it
is recommended to have at least 2 large bore intravenous lines or a
central line before surgical incision and fluids or blood available
g. Airway difficulty or aspiration risk. Where a potentially high-risk airway is
identified, at a minimum the approach to anaesthesia should be
adjusted accordingly, emergency equipment must be accessible and a
capable assistant should be physically present during induction.
Symptomatic active reflux or a full stomach should also be handled with
a modified plan
h. Known allergies – all members of team need to be aware
i. Anaesthesia safety checks complete (equipment, medications,
emergency medications, patient’s anaesthetic risk)
2. Time out – after induction and before surgical incision, entire team
a. Each team member introduces him/herself by name and role
b. Pause to confirm correct operation for correct patient on correct site.
Anaesthetist, nurse and surgeon should all individually confirm
agreement, plus the patient if awake
c. Review anticipated critical events
i. Surgical critical/unexpected steps, operative duration, anticipated
blood loss
ii. Anaesthetic patient specific concerns, for example, intention to use
blood products, co-morbidities
iii. Nurses confirm sterility of instruments and discuss equipment
issues/concerns
d. Confirm prophylactic antibiotics where required, was given within the 60
minutes prior to skin incision. If not given and required, administer prior
to incision. If >60 minutes, consider re-dosing the patient
e. Essential imaging displayed as appropriate

3. Sign out – during or immediately after wound closure, before moving the

patient out of the operating room, whilst
surgeon still present
a. Confirm operation performed and recorded

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b. Check instrument, sponge/swab and needle counts are complete. Where
numbers do not reconcile the team should be alerted and take steps to
investigate
c. Check surgical specimens labelled correctly
d. Highlight equipment issues
e. Verbalize plans or concerns for recovery and postoperatively, especially
any specific risks

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15
Why safe surgery is important

Surgical care has been an essential component of health care worldwide for
over a century. As the incidences of traumatic injuries, cancers and
cardiovascular disease continue to rise, the impact of surgical intervention on
public health systems will continue to grow.

Surgery is often the only therapy that can alleviate disabilities and reduce the
risk of death from common conditions. Every year, many millions of people
undergo surgical treatment, and surgical interventions account for an
estimated 13% of the world’s total disability-adjusted life years (DALYs).

While surgical procedures are intended to save lives, unsafe surgical care can
cause substantial harm. Given the ubiquity of surgery, this has significant
implications:

 the reported crude mortality rate after major surgery is 0.5-5%;

 complications after inpatient operations occur in up to 25% of patients;
 in industralized countries, nearly half of all adverse events in
hospitalized patients are related to surgical care;

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  at least half of the cases in which surgery led to harm are considered
preventable;
 mortality from general anaesthesia alone is reported to be as high as
one in 150 in some parts of sub-Saharan Africa.

WHO and surgical safety

WHO has undertaken a number of global and regional initiatives to address

surgical safety. Much of this work has stemmed from the WHO Second Global
Patient Safety Challenge “Safe Surgery Saves Lives”. Safe Surgery Saves Lives
set about to improve the safety of surgical care around the world by defining a
core set of safety standards that could be applied in all WHO Member States.

To this end, working groups of international experts were convened to review

the literature and the experiences of clinicians around the world. They reached
consensus on four areas in which dramatic improvements could be made in
the safety of surgical care: surgical site infection prevention, safe anaesthesia,
safe surgical teams and measurement of surgical services.

Member States have continued to be active in addressing these issues. Much

of this work has been initiated by the global implementation of the WHO
Surgical Safety Checklist, a 19-item tool created by WHO in association with
the Harvard School of Public Health.

USE OF THE SURGICAL SAFETY CHECKLIST TO IMPROVE

COMMUNICATION AND REDUCE COMPLICATIONS

Existing evidence suggests that communication failures are common

in the operating room, and that they lead to increased complications, including
infections. Use of a surgical safety checklist may prevent communication
failures and reduce complications. Initial data from the World Health
Organization Surgical Safety Checklist (WHO SSC) demonstrated significant
reductions in both morbidity and mortality with checklist implementation. A

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growing body of literature points out that while the physical act of “checking
the box” may not necessarily prevent all adverse events, the checklist is a
scaffold on which attitudes towards teamwork and communication can be
encouraged and improved. Recent evidence reinforces the fact the compliance
with the checklist is critical for the effects on patient safety to be realized.

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