Surgical safety - Wiley Online Library

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(e-mail: m.a.[email protected]). Published online in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9162. The report To Err is Human: Building.
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Surgical safety K. Ram and M. A. Boermeester Department of Surgery (suite G4-132.1), Academic Medical Centre, Postbox 22660, 1100 DD Amsterdam, The Netherlands (e-mail: [email protected])

Published online in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9162

The report To Err is Human: Building a Safer Health System, released in 1999 by the Institute of Medicine (IOM), posed an important question: ‘Must we wait another decade to be safer in our health system?’. This landmark in patient safety awareness suggested that 44 000–98 000 deaths every year resulted directly from medical errors that could be, and should have been, prevented1 . According to a systematic review of nearly 75 000 medical records in various high-income countries, an adverse event occurs in one of 11 patients in hospital. More than half are associated with a surgical procedure2 . In the decade since the IOM report, much has been written about this subject, illustrating the raised awareness regarding preventable medical errors and patient harm3 . Patient safety publications increased from 59 to 164 articles per 100 000 in MEDLINE4 . Not only has awareness increased, but there has been a change in safety culture. The way we think about surgical safety has changed for the better and promising interventions, such as the use of operative checklists, have been studied extensively, and in many places used routinely. Twenty years ago it was a common belief that bad doctors or nurses were the main cause of poor-quality healthcare and medical errors5 . In that ‘blame, name and shame’ culture, people sought the guilty healthcare provider. This led to a situation in which care givers were afraid to report ‘near-miss’ incidents. An accurate overview of the cause of safety issues was lacking, so solutions could not be aimed at the root of the problem.  2013 British Journal of Surgery Society Ltd Published by John Wiley & Sons Ltd

The recent shift to a system approach and a more open culture has paved the way for changes in patient safety policy. Mishaps are seldom related to the actions of an individual; errors and unsafe situations occur because of failing systems. The focus is now on changing systems to prevent individuals making mistakes3,6,7 . Complications, errors and performance are better recorded, and this information can be used to identify problem areas and improve systems. Studies of human factors describe the relationship between people, the environment in which they work, and the instruments and equipment they use. This comprises interactions such as communication, teamwork and organizational culture. Hospital processes should be designed such that different layers can influence the risk of harmful events, helping to intercept errors and minimize their impact6 . Understanding human factors has led to reductions in hours of work for doctors in several countries. Fatigue, stress, hunger and illness impair information handling, affecting judgement and actions8 – 10 . Other important contributory risk factors include dangerous behaviour owing to inexperience, insufficient supervision, or inadequate execution of a procedure as a result of lack of preparation or attention. Although a low stress level can be counterproductive, leading to boredom and inattention, high stress levels and lack of time lead to shortcuts, contributing to errors. Obvious factors such as language and cultural differences can lead to communication difficulties.

Human memory is neither endless nor flawless. Interventions such as checklists prevent dependence on memory. Prestige and hierarchy define the relationships between surgical teams. It is imperative that all team members, without restrictions due to hierarchy, feel free to address issues that can influence patient outcome adversely. As part of the World Health Organization’s campaign ‘Safe Surgery Saves Lives’, a structured surgical checklist emerged in 2009. This extended time-out procedure is a perioperative checklist consisting of three parts: the ‘sign in’ right before induction of anaesthesia, ‘sign out’ after anaesthesia and before the skin incision, and ‘sign out’ once the surgery is complete and before the patient is transported to recovery. Its effect has been studied in four hospitals in low–middle-income and four high-income countries, with a 4 per cent absolute reduction in perioperative complications. Overall, the mortality rate decreased by 0·7 per cent, and even in high-income countries the in-hospital mortality rate fell by 0·3 per cent11 . The year in which these results were published, use of the checklist became mandatory in the UK12 . A more comprehensive checklist, the SURgical PAtient Safety System (SURPASS), has been developed and validated in the Netherlands13 . This checklist is customized for the surgical patient, is multidisciplinary, contains more information, focuses on transfer moments, and follows the surgical pathway from admission to discharge

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Comparison of World Health Organization and SURgical PAtient Safety System checklist characteristics

Disclosure

Table 1

WHO Location

Operating room

Timing

Directly before and after operation Surgeon, anaesthetist, scrub nurse

Disciplines involved

Implementation Range

Relatively easy Limited

The authors declare no conflict of interest .

SURPASS Ward, holding, operating room, recovery From (before) admission until discharge Ward doctor, ward nurse, surgeon, anaesthetist, scrub nurse, recovery nurse Relatively difficult Extensive

References

WHO, World Health Organization; SURPASS, SURgical PAtient Safety System.

(Table 1). An effectiveness study conducted in 11 hospitals in the Netherlands showed the mortality rate was reduced by half (from 1·5 to 0·8 per cent) and the incidence of complications decreased by one-third (from 27·3 to 16·7 per cent; 10·6 per cent absolute risk reduction)14 . The digital version of SURPASS connects with hospital information systems, further simplifying its use and implementation. Checklists have received a lot of international attention. When Health Care Inspectorates and national guidelines demanded hospitals all over the world use a surgical checklist, implementation received a boost. It is essential to identify the parts that make a surgical checklist effective. Some redundancy in checks must be allowed, but an overload probably makes checklists less effective. The majority of preventable incidents occur before surgery, after admission but before the patient taken to theatre. The hospital setting and established surgical pathways restrict the items that can be checked on, or before, admission. Ideally, the checks should occur long before induction of anaesthesia. Important determinants of success or failure of checklists include the safety culture in a hospital, the level of system thinking and awareness of human factors.  2013 British Journal of Surgery Society Ltd Published by John Wiley & Sons Ltd

A number of other interventions may improve patient safety. These include educational issues, such as training by simulation or serious gaming, and improving communication and teamwork by crew resource management training. Clustering of low-volume/high-risk operations in specialized hospitals by multidisciplinary teams is known to improve outcomes, and relies on accurate patient information using digital patient records that make critical information available for all care givers. Finally, because sleep deprivation and a combination of fatigue and high workload are recognized as risk factors for medical errors, adequate rest and enforced maximum hours of work should be encouraged. Intermittent evaluation using effect measurement is essential for feedback, and to make necessary adjustments. Evaluation of surgical performance requires collection of data using a prospectively created database with accurate complication coding. Patient safety management will benefit from improved data to guide and prioritize treatment choices: evidence-based surgical safety instead of rule-driven safety. Surgeons, not governments or inspectorates, should lead the necessary changes to improve surgical safety. www.bjs.co.uk

1 Kohn LT, Corrigan JM, Donaldson MS (eds). To Err is Human: Building a Safer Health System. National Academy Press: Washington, DC, 1999. 2 de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care 2008; 17: 216–223. 3 Longo DR, Hewett JE, Ge B, Schubert S. The long road to patient safety: a status report on patient safety systems. JAMA 2005; 294: 2858–2865. 4 Stelfox HT, Palmisani S, Scurlock C, Orav EJ, Bates DW. The ‘To Err is Human’ report and the patient safety literature. Qual Saf Health Care 2006; 15: 174–178. 5 Berwick D. Continuous improvement as an ideal in health care. N Engl J Med 1989; 320: 53–56. 6 Reason J. Human error: models and management. West J Med 2000; 172: 393–396. 7 Leape LL, Berwick DM. Five years after To Err is Human: what have we learned? JAMA 2005; 293: 2384–2390. 8 Dawson D, Reid K. Fatigue, alcohol and performance impairment. Nature 1997; 388: 235. 9 Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT et al. Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med 2004; 351: 1838–1848. 10 Chu MW, Stitt LW, Fox SA, Kiaii B, Quantz M, Guo L et al. Prospective evaluation of consultant surgeon sleep deprivation and outcomes in more than 4000 consecutive cardiac surgical procedures. Arch Surg 2011; 146: 1080–1085. 11 Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat A-HS, Dellinger

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EP et al.; Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009; 360: 491–499. 12 McConnell DJ, Fargen KM, Mocco J. Surgical checklists: a detailed review of their emergence, development, and

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relevance to neurosurgical practice. Surg Neurol Int 2012; 3: 2. 13 de Vries EN, Hollmann MW, Smorenburg SM, Gouma DJ, Boermeester MA. Development and validation of the SURgical PAtient Safety System (SURPASS) checklist. Qual Saf Health Care 2009; 18: 121–126.

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14 De Vries EN, Prins HA, Crolla RMPH, Den Outer AJ, Van Andel G, Van Helden SH et al.; SURPASS Collaborative Group. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med 2010; 363: 1928–1937.

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