Patient safety in operating theatres in Bangladeshkth.diva-portal.org/smash/get/diva2:739841/FULLTEXT01.pdf · Patient safety in operating theatres in Bangladesh Patients kerhet i

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Patient safety in operating theatres in Bangladesh

SARA NORÉN M ICHAELA S JÖDIN

Bachelor of Science Thesis in Medical Engineering Stockholm 2014

Patient safety in operating theatres in Bangladesh

Patientsäkerhet i operationssalar i Bangladesh

S A R A N O R É N

MICHAELA SJÖDIN

Bachelor of Science Thesis in Medical Engineering Basic level (first cycle), 15 credits

Supervisor at KTH: Mannan Mridha Examiner: Lars Gösta Hellström

School of Technology and Health TRITA-STH. EX 2014:45

Royal Institute of Technology KTH STH

SE-141 86 Flemingsberg, Sweden http://www.kth.se/sth

Abstract

Background

Because of extreme population and a lack of resources the risk of beeing harmedwhile admitted to a hospital in Bangladesh is big. Mistakes made at operatingtheatres can result in devastating consequences, but by evaluating the patientsafety that risk can be minimized. Right now Bangladesh is in the middle ofan industrialisation that is contributing to the growing need for an expandinghealth care. The country is regularly suffering from cyclones, tsunamis andmonsoon rains and there is an urgent demand for safe health care.

Method

The aim of this thesis was to study the physical structure, organisation andpractice at operating theatres in Bangladesh. At three private and two publichospitals 14 operating rooms in total were visited and the basic equipment wasexamined. Managers, physicians, nurses and technicians were interviewed at allhospitals, 41 people in total participated in the study.

Results

The temperature control was not up to standard, bigger storages were neededand none of the public hospitals had enough washing equipment for properscrubbing. Only one hospital could monitor the patient’s body temperatureduring surgery and proper resuscitation equipment was missing in half of theoperating rooms. The autoclave process could not keep up with the surgeriesand delays were not unusual. The cleaning staff had no training in patient safetyand the staff found that the nurse’s education was not enough. The reportingof mistakes rarely reached the management and a written report was unusual.

Discussion

Most of the staff did not know what calibration meant and there were onlybiomedical departments at two of the hospitals. Even though training was re-quested by the staff the management did not plan for any changes. This showsthat it is the organisation, not the human errors, that is the source to theunstable situation of health care. The lacking of the reporting system is an-other reason for the slow development. Staff with technical knowledge must beavailable at the hospitals in order to help prevent risks and all hospitals shouldestablish a biomedical department. Patients had to lie on the floor, due to theshortness of space. This is not good for patient safety, but the alternative wouldbe that they would end up with no help at all. The outcome of patient safetyshould always result in better health for the people. The personal had this viewof thinking and they showed great engagement to their work.

Key words: Patient safety, Bangladesh, operating theatres, operating rooms

Sammanfattning

Bakgrund

På grund av extrem befolkningsmängd och brist på resurser är risken för att bliskadad av sjukvården i Bangladesh stor. Misstag inom kirurgin ger förödandekonsekvenser, men genom att utreda patientsäkerheten kan risken minimerasavsevärt. Bangladesh befinner sig just nu i en industrialisering som bidrar tilldet ökande behovet av vård. Flodvågor, översvämningar och stormar drabbarlandet regelbundet och efterfrågan på säker sjukvård är akut.

Metod

Patientsäkerheten analyserades genom att undersöka den fysiska miljön, organi-sationen och den praktiska utövningen i operationssalar. På tre privata och tvåstatliga sjukhus i Bangladesh besöktes sammanlagt 14 operationsrum, där dengrundläggande utrustningen utvärderades. Avdelningschefer, läkare, sköterskoroch tekniker intervjuades på samtliga sjukhus, totalt är 41 anställda med i stu-dien.

Resultat

Temperaturkontrollen var bristfällig, bättre förvaringsmöjligheter efterfrågadesoch ingen av de statliga sjukhusen hade tillräcklig utrustning för att tvättahänderna rätt. Endast ett sjuhus kunde övervaka patientens kroppstemperaturoch återupplivningsutrustning saknades på hälften. Sterilisering av instrumentkunde inte ske i samma tempo som operationerna och förseningar var vanligt.Städpersonalen hade ingen träning i patientsäkerhet och det fanns ett missnöjeöver sköterskornas utbildning. Rapportering av misstag gick sällan till sjukhus-ledningen och skriftlig rapportering var sällsynt.

Diskussion

De flesta av de tillfrågade visste inte vad innebörden av kalibrering var ochendast två av sjukhusen hade en medicinteknisk avdelning. Trots att vidareut-bildning efterfrågades av personalen hade ledningen inga planer på förändringar.Detta visar på att det är organisationen, inte de anställdas misstag, som är källantill den osäkra sjukvården. Den otillräckliga rapporteringen är också en anled-ning till varför utvecklingen hämmas. Tekniskt kunniga personer måste finnastillgängliga på sjukhusen för att förebygga risker och varje sjukhus bör organi-sera en medicinteknisk avdelning. På grund av platsbrist låg många patienterpå golvet. Detta är självklart inte bra för patientsäkerheten, men alternativetskulle vara att de inte fick någon hjälp alls. Synen på patientsäkerhet måstealltid inkludera att hälsan i sin helhet förbättras, den insikten hade personalenpå sjukhusen och de visade stort engagemang.

Key words: Patientsäkerhet, Bangladesh, operationsavdelningar, operations-salar

Preface

This work could not have been done without the help of Prof. Mohammad Sai-ful Islam from Bangabandhu Sheikh Mujib Medical University, Dhaka, and Dr.Mannan Mridha from the Royal Institute of Technology, Stockholm. Their su-pervising made this study possible. We thank you both for your concern.

The help of Nazmul Alim from Gono Bishwabidyalay University was of greatsupport and we would like to thank him for his compassion.

The personnel at the hospitals GK1, BSMMU2, BIRDEM3, DMC4 and SQUA-RE met us with warm hospitality and even though they had much to do theygave us answers to all our questions.

Michaela SjödinSara Norén

KTH STH, 14 May 2014

1Gonoshasthaya Kendra2Bangabandhu Sheikh Mujib Medical University3Bangladesh Institute of Rehabilitation for Diabetic Endocrine and Metabolic Diseases4Dhaka Medical College

This study has been carried out within the framework of the Minor Field Studies Scholarship Programme, MFS, which is funded by the Swedish International Development Cooperation Agency, Sida. The MFS Scholarship Programme offers Swedish university students an oppor-tunity to carry out two months’ field work, usually the student’s final degree pro-ject, in a country in Africa, Asia or Latin America. The results of the work are presented in an MFS report which is also the student’s Bachelor or Master of Sci-ence Thesis. Minor Field Studies are primarily conducted within subject areas of importance from a development perspective and in a country where Swedish in-ternational cooperation is ongoing. The main purpose of the MFS Programme is to enhance Swedish university students’ knowledge and understanding of these countries and their problems and opportunities. MFS should provide the student with initial experience of conditions in such a country. The overall goals are to widen the Swedish human resources cadre for engagement in international development cooperation as well as to promote scientific exchange between unversities, research institutes and similar authorities as well as NGOs in developing countries and in Sweden. The International Relations Office at KTH the Royal Institute of Technology, Stockholm, Sweden, administers the MFS Programme within engineering and applied natural sciences. Erika Svensson Programme Officer MFS Programme, KTH International Relations Office

KTH, SE-100 44 Stockholm. Phone: +46 8 790 6561. Fax: +46 8 790 8192. E-mail: [email protected] www.kth.se/student/utlandsstudier/examensarbete/mfs

Contents

1 Introduction 1

2 Aims and Objectives 2

3 Background 33.1 Patient safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33.2 The surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33.3 The reporting system . . . . . . . . . . . . . . . . . . . . . . . . . 43.4 Private and public hospitals . . . . . . . . . . . . . . . . . . . . . 4

4 Method and materials 5

5 Results 75.1 Physical aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . 75.2 Technological equipment . . . . . . . . . . . . . . . . . . . . . . . 85.3 Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

5.3.1 Education and training . . . . . . . . . . . . . . . . . . . 95.3.2 Communication and information . . . . . . . . . . . . . . 105.3.3 Policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105.3.4 Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

6 Discussion 116.1 Education and training . . . . . . . . . . . . . . . . . . . . . . . . 116.2 Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126.3 Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126.4 Infection control . . . . . . . . . . . . . . . . . . . . . . . . . . . 136.5 Basic equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . 136.6 Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

7 Conclusion 15

8 Bibliography 16

Appendix A Questionnaires

Appendix B Checklist

Appendix C Explanation of Checklist

Chapter 1

IntroductionIt is now widely accepted that about 10% of all patients admitted to a well-funded and technologically advanced hospital setting will be unintentionallyharmed in some way (WHO 2013a). Surgically related errors are second only tomedication errors as the most frequent cause of error-related death. The peri-operative environment is a high-risk area with high complexity and high stakes(Schimpff 2007). By making patient safety a priority many of those risks canbe minimized, leading to fewer adverse events and a safer hospital environmentfor both patients and personnel.

In low-income countries, such as Bangladesh, the risk of being harmed in thehospital is about 20 times higher than in industrialized nations (WHO 2013a).The knowledge of patient safety is scarce and the funds are not big enough tomake the changes required. The aim of this thesis is to study the physical struc-ture, organization and practice in operating theatres in Bangladesh in terms ofpatient safety.

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Chapter 2

Aims and ObjectivesThe aim of this thesis is to study the physical structure, organization and prac-tice in operating theatres in Bangladesh in terms of patient safety.

The objectives are:

• Ascertain of the basic essential equipment, the fundamental usability ofthe operating room and quality of staff

• Assess the quality and current functional status of the present technolog-ical equipment and room supplies

• Examine the backup and maintenance activities concerning electricity andrelevant medical equipment

• Observe the human behaviour related to patient safety regarding manage-ment, communication and policies

• Suggest measures that will improve and help raise awareness of patientsafety in operating theatres

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Chapter 3

BackgroundThe risks of providing health care are a serious global issue. Errors and adverseevents are made by shortages in hygiene and lack of knowledge of the equipment(Weiser et al. 2008). Bangladesh is one of the most densely populated countriesin the world with a growing population that will reach 200 millions in a coupleof decades. The society is hierarchically, half of the people are living under onedollar per day and the corruption is well known. The land is suffering fromcyclones, tsunamis and monsoon rains, which are leading to big overflows andhuge suffering for the people (Landguiden 2014). On top of these injuries, infec-tions and diseases are rising, due to the chaotic traffic situation and the criticalindustrialisation (Weiser et al. 2008). There are 4 hospital beds, 3 physiciansand 2.8 nurses per 10 000 persons in Bangladesh (WHO 2013b). This creates aheavy work load at the hospitals and the pressure on the personnel is untenable.

3.1 Patient safety

Health care is often delivered with risks, especially in surgery. Patient safety isto minimize this risk. In order to create an environment with patient safety themain change is to move from blame culture to learning culture (Amarapathyet al. 2013). Patient safety is based on the understanding that errors occurbecause of problems within the structure of which health care is delivered, notbecause of unprofessional behaviour. Strong evidence shows that a culture ofblame threatens the learning ability from errors and thereby threatens the abil-ity to improve the health care (WHO 2013a).

In low-income countries like Bangladesh, at least 50% of the medical equipmentis unusable or partly unusable (Weiser et al. 2008). Often the equipment is notused due to lack of skills or commodities (WHO 2006). This leads to poor diag-noses and the treatment can be hazardous. The patient safety is in big dangerand the results are serious injuries or death (Weiser et al. 2008). Estimationsmade in the SEA (South-East Asia) region shows that only 61% of the blooddonations are proven to be safe, 50% of all injections made is unsafe and 1000tons of health care waste are disposed improperly each day (WHO 2006).

It is important to mention that there is little evidence concerning the unsafe carein low-income countries, but with accurate statistics from hi-income countriesand with infrastructure, technologies and human resources in consideration it ispossible to make estimations (WHO 2013a).

3.2 The surgery

Each year 4% of the world’s population is going under surgery, which indicatesthat the safety during operations is of big importance. With the epidemiologicaltransition in mind, surgery will assume an increasing role in public health. Be-cause of the risks, the complexity and the quantity of surgeries there is therefore

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CHAPTER 3. BACKGROUND 4

essential to improve its safety. Only a third of the 192 member states of WHO(World Health Organization) could offer data for surgical volume. This showshow inadequate present health care surveillance is (Weiser et al. 2008).

The planning of the operating room is important in order to keep the patientand the personnel safe. Temperature, operating light and fire safety are someexamples. Due to the cost cutting, vital requirements are often overlooked(Ehrenwerth 2011). A biomedical department who is responsible for the electri-cal equipment is usually only present at private hospitals. These hospitals showbetter results in maintenance (Palmqvist Isaksson & Afroze 2012).

3.3 The reporting system

To provide a good reporting system, any mistake should be seen as an oppor-tunity to improve. Open communication is one of the most important qualitiesand this is the main source for learning from errors. Well established patientsafety cultures consists of these components; willingness to report, analyzingof information, implementation of appropriate changes, openness about errors,balance between just culture and patient safety improvement, flexibility, as-sessment of patient safety and measurements of outcomes in understandablevariables (Amarapathy et al. 2013).

The unsafe patient care in Bangladesh is a result of the health care systemsrather than due to human errors. The roots of these adverse events can begeneralized and corrected in order to make the health care safer. In a blameculture the individuals are not likely to report errors, it is therefore importantto focus on the systems rather than on blaming individuals. A transparent andeffective reporting system is needed (WHO 2006).

3.4 Private and public hospitals

Public hospitals are mostly dependent on tax subsidies and only small chargesfrom the patients are required. Since private hospitals only depend on incomefrom clients they are more motivated to meet their needs (Andaleeb 2000).Since the cost at a private hospital is about ten times higher than at a publichospital the care given is generally of a higher quality (Palmqvist Isaksson &Afroze 2012). Semi-private and semi-public hospitals are a hybrid of both typesof hospitals.

Chapter 4

Method and materialsThe field study was conducted during a period of eight weeks in Bangladesh(between March and May 2014). The aim of this thesis is to study the physicalstructure, organisation and practice in operating theatres in terms of patientsafety.

There are five hospitals included in the study; two private, one semi-private,one public and one semi-public. Of the five hospitals visited, four is located incentral Dhaka and one is located in Savar (outside of Dhaka). The hospitalsincluded in the study are:

• Gonoshasthaya Kendra Hospital (GK) [Private]

• SQUARE Hospital [Private]

• Bangladesh Institute of Rehabilitation for Diabetic Endocrine and MetabolicDiseases (BIRDEM) Hospital [Semi Private]

• Dhaka Medical College (DMC) Hospital [Public]

• Bangabandhu Sheikh Mujib Medical University (BSMMU) [Semi Public]

A questionnaire was constructed with questions regarding different aspects ofpatient safety in operating theatres. The questions are divided into three groups;physical aspects, technical equipment and management. The data was collectedthrough interviews with personnel at three different kinds of operating theatresat each hospital. One manager, three physicians, three nurses and three tech-nicians were interviewed per hospital, 44 interviews in total. At GK only oneoperating theatre with tree different operating rooms where available, only onepersonnel per profession was interviewed here. The same questions were askedto different professions in order to get different perspectives on the questionsand the interviews were made with one person at the time. If a question wasnot applicable to a personnel of some profession, the same question was notasked. The interviews were held in English. If the person interviewed did notunderstand the question in English, the question was translated to Bengali by apresent translator. Because of the langage barrier, mostly closed questions wereused to make sure the answeres were as clear as possible. The questionnaire isavailable in Appenix A.

A checklist was used to collect data on the physical aspects and the technicalequipment in the operating rooms. It was constructed based on already existingstandards for technical equipment and supplies in ORs. The checklist was filledout by observing the operating room and asking additional questions to find outif the room and the medical equipment were up to standard. At each hospitalthree operating rooms of different types were checked, 15 operating rooms intotal. The checklist and a document explaining how the checklist was used areavailable in Appendix B and Appendix C.

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CHAPTER 4. METHOD AND MATERIALS 6

In the interviews notes were taken by hand and afterwards the notes were com-pared to be able to transcribe the interviews correctly. The transcribed answerswere inserted into a chart in order to be able to compare the answers betweenhospitals and categories of personnel for the result part.

Names of people that participated in the interviews are left out of this thesis.There are only referrals to what kind of operating room or which category ofpersonnel the results belong to. The names of the participating hospitals arekept secret in the result and discussion parts of the thesis. Because it is morerelevant for the result we only refer to the hospitals as public or private insteadof the name.

The abbreviations OR (operating room) and OT (operating theatre) is fromnow on used through out the thesis. OR is the room the operation is performedin and OT is the department where the staff and ORs are found.

Chapter 5

ResultsOf the 15 ORs included in the method, only 14 could be observed. At one ofthe private hospitals there were no OR in the emergency OT that was used foroperations. At this hospital all surgical cases were moved to the most suitableOT when arriving to the hospital. At one public hospital there were only onetechnician for all three ORs. Because of these two reasons only 39 people wereinterviewed in total.

5.1 Physical aspects

The temperature control was not up to standard in most of the hospitals. Fourout of five hospitals controlled the temperature by controlling the air condi-tioner. Only one OR in a private hospital had a thermometer on the wall to beable to see the actual room temperature and not only the temperature the ACwas set on. Eleven people in total said that they didn’t know the room temper-ature and many of the remaining people gave the temperature the AC was seton. Only 7 people said that they calibrate the room temperature periodicallyin the OR out of which 5 was working at private hospitals. Only one privatehospital had standard ventilation system, a positive pressure and humidity con-trol in the ORs. At one of the public hospitals a nurse told us about a problemwith patients going into hypothermia during operation.

In one public and one private hospital 2 out of 3 persons asked said that theyneeded a bigger storage in the operating theatre. In the OR of the publichospital the supplies did not have their own space and many unnecessary itemswere in the room.

Hospital Enough equipment Not enough equipment

Private 5 3Public 0 6

Table 5.1: Washing equipment in ORs

The private hospitals had almost all equipment they needed, except from in oneOR where only minor surgeries were performed. The public hospitals all neededimprovement or did not have enough equipment. At one of the public hospitalsthe washing areas were very unclean and none of the public hospitals had allthe washing equipment needed (Table 5.1 ). None of the washing areas at anyof the hospitals had a timer to make sure the surgeons scrubbed long enough.

There were no automatic door closers at any of the hospitals, but many of thehospitals had doors that could be closed without the use of hands.

Out of 14 ORs in total there was a phone in 6 and an intercom in 8. In 4 ofthe ORs there were no communication devices at all. There were no emergency

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CHAPTER 5. RESULTS 8

bells or computers in any of the ORs visited. In case of emergency the staff toldsomeone or called on their mobile phone.

Only three of the 39 people interviewed said that they reuse disposable itemsand only for cleaning.

5.2 Technological equipment

The OR tables were up to standard at all hospitals except in one OR at a pub-lic hospital. That table was out of order and the height could not be adjusted.There where basic resuscitation equipment at half of the ORs in the privatehospitals and at none of the public hospitals.

All the basic equipment such as suction machine, diathermia, anesthesia andmonitoring equipment were present at all hospitals. Diathermia was not upto standard at two emergency ORs where the diathermia equipment was notpresent at all. One of these rooms was not used regularly and therefore did nothave all equipment present at the time of the visit. The anesthesia equipmentwas not up to standard in three of the emergency ORs, but it was only needfor local anasthesia in these rooms. The monitoring equipment was not up tostandard at two public hospitals were a lot of the criteria was missing (AppendixC ). Only the monitoring equipment at one of the private hospitals was showingthe patients’ body temperature. All hospitals have working backup power sup-ply and also backup of oxygen and suction in the OR or close by.

In the private hospitals staff from all professions said that they had enoughequipment. In the public hospitals the staff expressed that they lacked a lot ofequipment. At one public hospital they said among other things that they needmore surgical instruments, more special instruments and more powerful operat-ing lights. Staff from both private and public hospitals said that different kindsof equipment could use improvement. For example scissors that were not sharpenough and surgical instruments that sometimes was used for several years.

No hospitals had autoclave equipment in the OR. At three rooms in the pri-vate hospitals the autoclave equipment was in a connecting room. At one ofthe public hospitals the staff said that they had problems with the sterilization,because they did not always have time to autoclave everything and had to boilit two or three times a day instead. Sometimes the autoclave broke down be-cause of electricity problems. The staff at the other public hospital experienceda problem with the autoclave in another building and because of this it tooka long time to autoclave the equipment and they did not always have enoughinstruments.

All hospitals, except one private hospital, rate the performance of the theatrelights by their eyes and not with a special tool. Four people in public hospitalsthought that the operating lights are not good enough for safe surgery.

The answers collected regarding warranties are incoherent, staffs from the samehospitals were giving different answers. At two of the private hospitals the


biomedical department tries to fix the equipment before they send for help.

5.3 Management

82% of the physicians, nurses and technicians in the study could identify defi-ciencies in patient safety at their hospital. These problems are a summation oftheir thoughts.

The reporting system of both human errors and failure of the equipment isnot up to date. Due to the transport system, 6 hours of patient transportis usual. The limitation of surgical equipment is delaying the operations andthe delay is often related to the sterilization. Compared to the amount ofpatients the number of surgical instruments, autoclaves and employees are toolow. Absence of right blood group is also a factor in the delay. Because of thepoor temperature control and the long surgeries, patients are sometimes put inhypothermia. The bed sheets are not always changed between patients and thepersonnel is questioning the cleaning process of the patients before operation.

5.3.1 Education and trainingBoth physicians and managers at the public hospitals complained about thenurse’s poor education. The nurses did not think that the education lived upto the reality in the hospital. For most of the nurses the education was just sixmonth and the responsibility in the surgical department was bigger than theeducation could provide. Even though this fact was well known by the differentlevels of managers, training was only offered at one hospital. The nurses at theprivate hospitals had better education than the nurses at the public hospitalsand they were more pleased with their own effort. Training was only provided byone private hospital and none of the public hospitals. The nurses had to performtasks that were out of their experience and it was often related to equipment asdefibrillator, laparoscopy and anaesthesia equipment.

The technicians also had to perform tasks that were out of their experience.Handling the sterilisation mechanism, plaster patients and putting the patientin the right position were some examples.

None of the public hospitals offered training for the physicians. 27% of all theinterviewed physicians said that they sometimes had to perform tasks that wereout of their experience; all of them were working in a public hospital. Theprivate hospitals provided training, but not regularly and the physicians hadto apply for it. If the physicians felt that they didn’t have time for trainingor didn’t want to, they didn’t apply. The attitude to training was sometimespoor among the physicians. In some cases they thought their knowledge wascomplete and that no training was needed.

The cleaning personnel did not have proper training at any of the hospitals. Inmost cases gloves and dresses were used in order to keep them safe, but therewere no specific training according how to keep the patient safe. At one hospitalthe cleaning responsibility fell under the nurse’s duty.


5.3.2 Communication and informationThe managers’ image of communication between personnel was that everyoneunderstood each other well and no improvement was needed. Only one managerthought that the communication needed upgrading. At the public hospitals, aclear majority of both nurses and physicians thought that the nurse’s deficienteducation led to poor communication. This was not the case in the privatehospitals. The communication between the hospital leading and the staff wasgood at all hospitals and the personnel felt that they were heard when theyhad ideas about improvements. According to the interviews, the thoughts ofthe employees’ did reach the managers and breaches were instead present dueto shortness of resources.

Of the interviewed physicians, nurses and technicians 86% said that they wouldinform a physician if they saw that he or she could be an infection risk. Somenurses simply didn’t know when a physician could be an infection risk. Every-body felt comfortable telling a nurse if he or she was an infection risk.

In order to make sure that the right patient was on the operation table allhospitals asked for name and looked at the patient’s symptom. Only one of thehospitals had a patient computer system and tags on the patient’s wrist, thehospital was private.

5.3.3 PoliciesAll of the physicians in the study were vaccinated from hepatitis B, but only67% of the nurses. At one public hospital a manager told us that everyonewas vaccinated from hepatitis B, but one of the nurses claimed that she did nothave that vaccination. There was no specific protocol at any hospital concerninghow to clean the operating room. All hospitals stated that they had protocolsregarding hand washing and most of them a preoperative and postoperativechecklist, but the actual use and the form of the protocols varied and no exactdata was collected.

5.3.4 ReportingTwo of the five hospitals said that they had a standard reporting system re-garding both human errors and the failure of the equipment. The reporting ofhuman errors were 82% for the physicians and 90% for the nurses, but most ofthe reporting was performed by telling a senior colleague and not by making awritten report to the hospital manager. Only 18% of the physicians and 16% ofthe nurses confirmed that they reported to someone in the hospital leading andno one described an actual process of a reporting system.

Chapter 6

DiscussionThe patient safety in Bangladesh is threatened. Fundamental aspects like properhand washing and functional temperature control are out of order. These aspectsare highly related to risks of infection and hypothermia and with the complexityof a surgery this creates great danger. The understanding of errors is one of themost important parts in patient safety. Without a functional reporting systeminformation about errors is lost and as such is the key to improvement.

The fact that the interviews were not held in the personnel’s mother languagecould have affected the results. Although a translator translated the questionswhen a non English speaking person was interviewed it is possible that theanswers could have been different if the interviews were held in Bengali. Therelation between a low-income country and high-income country can also havecaused modified answers. Even though this could have affected some parts ofthe answers the method should be addressed as reliable due to the cross checkingof questions and observations with checklists. Thanks to the different levels ofinterviewed personal a broad view of the hospital environment could be studiedand the complexity of the hierarchy was confirmed.

One of the private hospitals differed a lot from the others. The costs of care wereextremely high compared to what a regular Bangladeshi citizen could afford.The information about this hospital is relevant in order to compare differenttypes of hospitals, but it gives an incorrect picture if the results are aimed toshow the quality of the health care that is provided to the people.

6.1 Education and training

The results showed that not only nurses, but also other personnel in the publichospitals wanted better education for the nurses. Still no training was provided.It was showed that there was a correlation between the nurses’ education andthe communication among the personnel. Communication gaps between peoplewith different levels of education could endanger the patient. Misunderstandingslead to more delays in the surgery and can result in that the wrong procedureis done. It is possible that the big difference in knowledge between physiciansand nurses also create a gap in the feeling of importance, responsibility andcontribution to patient safety.

Nurses, technicians and physicians at the public hospitals were all talking aboutthe lack of knowledge within the organisation. When the question about breachesin patient safety was asked to the managers, none of them spoke about the lackof training provided. The employees thought that their opinions did reach theupper level, but this does not seem to be the case. This is an important findingin order to look in to the hospitals analysing of information and implementationof changes, two of the fundamental components in patient safety. The essen-tial role of knowledge did not seem to be brought to the light, despite the factthat the staff had discovered the problem. This confirms WHO’s idea about

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CHAPTER 6. DISCUSSION 12

patient safety; it is the health care system rather than the human errors thatare maintaining the unsafe health care in Bangladesh (WHO 2006).

6.2 Reporting

The awareness about what a reporting system actually is appears to be de-ficient among the personnel and managers. The number of people who saidthat they were reporting their mistakes was high, but the fraction of the re-ports that reached the hospital leading was low. This indicates that few healthcare providers in Bangladesh know how a proper reporting system should work.Since the reports of errors within the organisation rarely reaches the people incharge there will be insufficient information to make changes. Because of thisthe working environment cannot be classified as a learning culture.

According to the result a strong majority both tell others about their own mis-takes and tell their colleague if he or she seems to be an infection risk. Thisgives the impression that the openness about errors is good. One aspect thatwas hard to measure was the questioned personnel’s openness to this project.As soon as there was a question about their own behaviour, the answer wasformed in a way of that they did their work without any fault. To preventthis problem, questions about reporting behaviour in other groups of employeeswere asked in order to cross check. This was the only way to gather informationabout none reporting. When the questions about their colleagues’ reportingbehaviour came up, most of personnel just gave a quick and short yes and onlythe persons that felt most relaxed answered no. This rather gives the impressionof a blame culture than openness to errors, even though the actual results areshowing the opposite. This makes it hard to collect reliable data. Still manyother aspects regarding patient safety could be collected and it was possible toget a good picture of the risks of providing health care in Bangladesh.

In one public hospital the halls were crowded and people were lying on the floorwaiting for help. This is of course not good for patient safety, but the alternativewould be that these people would get no help at all. The view of patient safetyshould always be considered in the same way. The patient safety in the operatingtheatre might increase if only half of the patients were treated, but that woulddecrease the health of the people in Bangladesh. The hospital staff are givinga huge part of their time to the patients and a genuine compassion to theirwork is present although the pressure on their performance is high. The patientsafety in Bangladesh seems to be a question about money and organisation, themotivation, engagement and concern is always present.

6.3 Communication

Communication is a big part of patient safety, if there is a misunderstandigbetween the staff it might lead to unnecessary mistakes that could be avoidedif the system for communication was better. In the ORs the communicationis done by telling someone in the room or close by and then that person tellssomeone else or uses their mobile phone. According to the staff this procedure is


the same if something is missing from the OR and for emergencies, such as a fire.This is of course be part of the organisation problem, but a simple solution canbe to have different ICT-tools (Information and Communication Technology-tools) available in the ORs. This can make sure that no misunderstandigs occurbecause there is a lack of communication devices. When there is a long chainof communication, from person to person, it is easy for information to be loston the way.

6.4 Infection control

At many of the visited OTs the washing station was not up to standard. A lot ofessential equipment, like nailbrushes and nailclippers, were missing. This kindof supplies is not expensive and can make a big difference in improving infectioncontrol. One surgeon said that she and her colleague reeds a prayer that isexactly 4,5 minutes long when doing their hand washing routine. A stop watchto measure time taken with the scrubbing is good to keep time, raise awarenessof the need for scrubbing carefully and remind the staff to keep up the routine.Also a simple thing like keeping the washing stations clean and presentable canmake a difference.

At the hospitals where the autoclave equipment is far from the OTs it is apossibility for the instruments to be contaminated before they reach the OR.When there are too few instruments and not enough staff to keep the ORssupplied with equipment there can be serious risks for the patient. The autoclaveneeds to be as close to the OR as possible to make sure that the patient can’tget infected by the instruments. A cost effective alternative to moving thesterilization department is to keep the instruments sealed up in airtight standardpacks when they are brought between the autoclave and the OTs. This way theequipment can be transported without the risk of being contaminated.

6.5 Basic equipment

The emergency OTs looked at were not prioritized at any of the hospitals, result-ing in malfunction or lacking equipment, fewer present personnel and washingstations not up to standard. The emergency ORs should be ready for surgeryand have the basic equipment present, otherwise patients might not get thetreatment needed in time. Especially resuscitation equipment should be presentin an emergency OR, which was missing from all of the ORs checked. The miss-ing emergency OR at one of the hospitals may also result in unnecessary risksfor the patient. For example, if the patient needs immediate help and no otherORs in the hospital are available, or if the staff can’t get the patient to anotherOT in time.

The results from the checklist shows that only one hospital used anything otherthan an air conditioner for ventilation and temperature control. A lot of timesthe OR staff did not know the actual temperature of the room, which can bemeasured with a simple thermometer on the wall. This shows that there is alot that could be improved in that area. In a warm country like Bangladesh it


is extra important to be able to adjust temperature, humidity and air pressureof the room and it should be more prioritized. The body temperature of thepatient is not measured in any of the hospitals except for one of the privatehospitals. This, in combination with the room temperature might be the reasonthere is a problem with patients going into hypothermia at one of the publichospitals.

6.6 Maintenance

A lot of the people interviewed did not seem to know what calibration means,which may implicate that it is not performed. A confounding factor was that inmany of the hospitals nurses were responsible for the equipment and thereforewere interviewed as technicians. In most cases the checking of the equipmenthappens when there is a problem. If there is not a biomedical department atthat hospital or a technician that is capable of solving the problem, the com-pany from where the equipment is bought have to come and repair it. Thisis an expensive procedure and could be avoided if the equipment was kept ingood shape by calibrating and checking it regularly. As previously suggestedby T. Afroze and M. Isaksson Palmqvist there are good reasons to implement abiomedical department in all hospitals to be able to perform regular checks andcalibrations of the equipment (Palmqvist Isaksson & Afroze 2012).

An other cost-effective change is to improve the disposition of the OR. Itemslike files and papers do not belong in the OR, but should have its own spaceoutside the room. This is an organisation problem that seemed to occur mostlyat the public hospitals visited, where there were not enough personnel.

Chapter 7

ConclusionThe physical structure, organization and practice has been investigated at op-erating theatres in Bangladesh and some of the main problems we found arereporting, education, communication and maintenance of equipment. A realsystem for reporting has to be developed in order for the information to reachall people concerned. Education of nurses has to be more fundamental and thereshould be a possibility of re-training available for all staff. The communicationbetween the personnel could be improved by a better reporting system, but alsoif more ICT-tools were present at the ORs to make the chain of communica-tion shorter. Technically skilled personnel should be present at all hospitals tomaintain and calibrate the equipment. These changes may take funds to estab-lish, but it will make the operating environment safer for the patient and helpminimize the risks of surgery.

15

Chapter 8

BibliographyAmarapathy, M., Sridharan, S., Perera, R. & Handa, Y. (2013), ‘Factors Af-fecting Patient Safety Culture In A Tertiary Care Hospital In Sri Lanka’,2(3).

Andaleeb, S. S. (2000), ‘Public and private hospitals in bangladesh: servicequality and predictors of hospital choice’, Health Policy and Planning 15(1), 95–102.

Ehrenwerth, J. (2011), ‘Chapter 2 the anesthesiologist ’ s overview of the oper-ating room’, Operating Room Manual pp. 16–36.

Landguiden (2014), ‘Landguiden [online][cited: april 15, 2013]’.URL: https://www.landguiden.se/Lander/Asien/Bangladesh

Palmqvist Isaksson, M. & Afroze, T. (2012), ‘Patient safety regarding medicaldevices at icus in bangladesh’.

Schimpff, S. C. (2007), ‘Improving operating room and perioperative safety:background and specific recommendations.’, Surgical innovation 14(2), 127–35.URL: http://www.ncbi.nlm.nih.gov/pubmed/17558019

Weiser, T. G., Regenbogen, S. E., Thompson, K. D., Haynesand, A. B., Lipsitz,S. R., Berry, W. R. & a Gawande, A. (2008), ‘An estimation of the globalvolume of surgery: a modelling strategy based on available data.’, Lancet372(9633), 139–44.URL: http://www.ncbi.nlm.nih.gov/pubmed/18582931

WHO (2006), ‘Technical discussions on promoting patient safety at healthcare institutions’, Regional committee, Fifty-ninth Session SEA/RC59/Inf.4.Dhaka : WHO .

WHO (2013a), Ethical issues in patient safety research: interpreting existingguidance, isbn 978 92 4 150547 5 edn, World Health Organization.

WHO (2013b), ‘South-east asia region [online] [cited: april 15, 2014]’.URL: www.who.int/goe/publications/atlas/bgd.pdf

Appendix A

Questionnaires

PHYSICAL ASPECTS Chief

Physician

Nurse

Technician

Work load

1p. How many patients are operated each day? 2p. How many doctors work in this operating room per day?

i) How many nurses work in this operating room per day?

ii) How many nurses per surgery?

iii) Do you think that is enough?

1n. How many patients are operated each day? 2n. How many doctors work in this operating room per day?




1t. How many patients are operated each day? 2t. How many doctors work in this operating room per day?




Infection risk 1c. Is there any problems according to the sterilisation?

i) Is the sterilisations mechanism checked periodically?

ii) How often? 2c. Can you describe the decontamination of used medical devises?

3p. Is there any problems according to the sterilisation?


ii) How often?

4p. How often do you need to reuse disposable items?

i) What kind of items (needles, gloves, etc)?

ii) Have you seen other personnel reuse other items?

3n. Is there any problems according to the sterilisation?


ii) How often? 4n. How often do you need to reuse disposable items?

i) What kind of items (needles, gloves, etc)?

ii) Have you seen other personnel reuse other items?

3t. Is there any problems according to the sterilisation?


ii) How often?

5p. Can you describe the decontamination of used medical devises? 6p. Is there a general zone, a clean zone and an aseptic zone?

5n. Can you describe the decontamination of used medical devises? 6n. Is there a general zone, a clean zone and an aseptic zone?

Temperature control

7p. What is the temperature in the operating room?

i) Can you regulate the temperature?

ii) Is it calibrated periodically?

7n. What is the temperature in the operating room?



4t. What is the temperature in the operating room?



Order 3c. Is the storage big enough? 4c. Is everything that might be needed for the surgery in the room or do you have to leave the room to get it?

8p. Is the storage big enough? 9p. Is everything that might be needed for the surgery in the room or do you have to leave the room to get it?

8n. Is the storage big enough? 9n. Is everything that might be needed for the surgery in the room or do you have to leave the room to get it?

Emergency 5c. Is there a standard procedure for adverse events such as a fire?

i) Can you call for help easily? ii) Is there an emergency

response team?

10p. Is there a standard procedure for adverse events such as a fire?


response team?

10n. Is there a standard procedure for adverse events such as a fire?


response team?

5t. Is there a standard procedure for adverse events such as a fire?


response team?

TECHNOLOGICAL EQUIPMENT

Chief

Physician

Nurse

Technician

Backup

11p. Is there a backup supply of oxygen in the operating rooms?

i) Where? 12p. Is there a backup for suction apparatus in the operation theatres?

i) Where? 13p. Is there a backup power supply in case of a blackout?

i) Is it always working properly?

11n. Is there a backup supply of oxygen in the operating room?

i) Where? 12n. Is there a backup for suction apparatus in the operation theatres?

i) Where? 13n. Is there a backup power supply in case of a blackout?


6t. Is there a backup supply of oxygen in the operating room?

i) Where? 7t. Is there a backup for suction apparatus in the operation theatres?

i) Where? 8t. Is there a backup power supply in case of a blackout?


Operation light 6c. How do you rate the performance of the theatre lights?

14p. How do you rate the performance of the theatre lights?

i) Is the light good enough for a safe surgery?

14n. How do you rate the performance of the theatre lights?

i) Is the light good enough for a safe surgery?

9t. How do you rate the performance of the theatre lights?

i) Is there a protocol for this matter?

Anaesthesia

15p. How often does the anaesthesia equipment not work properly?

15n. How often does the anaesthesia equipment not work properly?

10t. How often does the anaesthesia equipment not work properly?

Warranties 7c. Are there warranties on the equipment?

i) What happens when it runs out?

16p. Are there warranties on the equipment?


16n. Are there warranties on the equipment?


11t. Are there warranties on the equipment?


Safety aspects 8c. Are all electrical instruments checked for risks periodically?

i) How often? 9c. Do you think that you got the right instruments and equipment in the operating room? 10c. Which of the instruments and equipment are not working properly in your opinion?

17p. Are all electrical instruments checked for risks periodically?

i) How often? 18p. Do you think that you got the right instruments and equipment in the operating room?

19p. Which of the instruments and equipment are not working properly in your opinion? 20p. Does the surgical equipment that is needed get delivered in standard packs?

i) Do you count the equipment before and after the surgery?

17n. Are all electrical instruments checked for risks periodically?

i) How often? 18n. Do you think that you got the right instruments and equipment in the operating room? 19n. Which of the instruments and equipment are not working properly in your opinion? 20n. Does the surgical equipment that is needed get delivered in standard packs?

i) Do you count the equipment before and after the surgery?

12t. Are all electrical instruments checked for risks periodically?

i) How often?

13t. What equipment are calibrated? i) How often is it done?

14t. Do you think that the operating room got the right instruments and equipment? 15t. Which of the instruments and equipment are not working properly in your opinion?

MANAGEMENT

Chief

Physician

Nurse

Technician

Training 11c. Does new personnel get proper training or is that made during the actual work time?

i) Physician? ii) Nurse? iii) Cleaning personnel?

12c. In what way do you provide you personnel with information regarding patient safety? 13c. What training has been given to the personnel that are cleaning the surgical room?

21p. Did you get new proper training when you were new here or was that made during the actual work time? 22p. Did you get enough information about patient safety during your training? 23p. Do you often perform tasks that are beyond your level of experience? 24p. What training has been given to the personnel that are cleaning the surgical room?

21n. Did you get new proper training when you were new here or was that made during the actual work time? 22n. Did you get enough information about patient safety during your training? 23n. Do you often perform tasks that are beyond your level of experience? 24n. What training has been given to the personnel that are cleaning the surgical room?

16t. Do you often perform tasks that are beyond your level of experience? 17t. What training has been given to the personnel that are cleaning the surgical room?

Reporting 14c. Do you have any regular reporting system regarding the failure of the equipment? 15c. Do you have any reporting system regarding the human errors of the personnel?

i) Do you report bad performance?

16c. Which breaches can you see in patient safety?

25p. Do you report if you make a mistake?

i) To who? ii) Do the nurses report their

mistakes? iii) To who? iv) Do you report a colleague’s

mistake? v) If no, why not?

26p. Which breaches can you see in patient safety?

25n. Do you report if you make a mistake?

i) To who? ii) Do the physicians report

their mistakes? iii) To who? iv) Do you report a colleague’s

mistake? v) If no, why not?

26n. Which breaches can you see in patient safety?

18t. Do you have any reporting system regarding the failure of the equipment? 19t. Which breaches can you see in patient safety?

Communication 17c. Is the communication between the staff good enough in order to keep the patient safe or can you see any shortages?

27p. Do you feel that the information you get from other personnel is enough for you in order to keep the patient safe? 28p. Do you think the nurses got enough education and training to understand the information you are giving them? 29p. Does anybody observe you to make sure that you are not an infection risk? 30p. What do you do when you see that a physician could be an infection risk?

27n. Do you feel that the information you get from other personnel is enough for you in order to keep the patient safe? 28n. Do you think you got enough education to understand the information you are giving them? 29n. Does anybody observe you to make sure that you are not an infection risk? 30n. What do you do when you see that a physician could be an infection risk? 31n. What do you do when you see that a nurse could be an infection risk?

20t. Do you feel that the information you get from other personnel is enough for you in order to keep the patient safe? 21t. What do you do when you see that a physician could be an infection risk? 22t. What do you do when you see that a nurse could be an infection risk?

31p. Do you have a clear definition of your task? 32p. Has anyone checked you while you do basic steps like scrubbing, gowning, etc? 33p. How can you make sure that the correct patient has been placed on the operating table?

32n. Do you have a clear definition of your task? 33n. Do you know if it is included in your work to look if the physicians are doing the basic steps (scrubbing, gowning, etc) right?

i) Do you feel that you always have time for this?

34n. How can you make sure that the correct patient has been placed on the operating table?

Policies 18c. Which personnel are vaccinated from hepatitis B? 19c. Do you use a preoperative and/or postoperative checklist of tasks in the OR? 20c. What safety precautions do the cleaning personnel following?

34p. Are you vaccinated from hepatitis B?

i) Have you heard of some one that got infected by a patient?

35p. Are you following any protocols regarding hand washing? 36p. Do you use a preoperative and/or postoperative checklist of tasks in the OR? 37p. What safety precautions do the cleaning personnel following?

35n. Are you vaccinated from hepatitis B?

i) Have you heard of some one that got infected by a patient?

36n. Are you following any protocols regarding hand washing? 37n. Do you use a preoperative and/or postoperative checklist of tasks in the OR? 38n. What safety precautions do the cleaning personnel following?

23t. Do you use a preoperative and/or postoperative checklist of tasks in the OR?

24t. What safety precautions do the cleaning personnel following?

Contribution 21c. Do you feel that you are contributing in the work of patient safety?

38p. Do you feel that you are contributing in the work of patient safety? 39p. Do you have thoughts about any deficiencies, but feel that there is no way for you to reach out with your thoughts?

39n. Do you feel that you are contributing in the work of patient safety? 40n. Do you have thoughts about any deficiencies, but feel that there is no way for you to reach out with your thoughts?

25t. Do you feel that you are contributing in the work of patient safety? 26t. Do you have thoughts about any deficiencies, but feel that there is no way for you to reach out with your thoughts?

Procurement 22c. Which of the members of the operating team is involved in planning the operating room?

i) Who is in charge of the procurement?

40p. Which of the members of the operating team is involved in planning the operating room?


41n. Which of the members of the operating team is involved in planning the operating room?


27t. Which of the members of the operating team is involved in planning the operating room?


Appendix B

Checklist

Checklist - Operating room

Hospital:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Type of operating room: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

OR lights:

No shadows Few shadowsMany

shadows

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Temperature control:

Workingproperly

Almostworkingproperly

Not working

properly

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

OR ventilation:

Workingproperly


Not working

properly

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Positive pressure ventilation:

Workingproperly


Not working

properly

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Humidity control:

Workingproperly


Not working

properly

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Room space:

Enough spaceJust enough

space

Not enough

space

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Room order and storage:

Very goodorder

Good order Bad order

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Backup power supply:

Workingproperly


Not working

properly

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Washing equipment:

Enoughequipment

Needsimprovement

No equipment

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Automatic door closers:

Workingproperly


Not working

properly

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Info-links:

Phone ComputerEmergency

bellIntercom

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Medical equipment:

Kind ofequipment

StandardNearly

standardNot standard

OR table

Resuscitationequipment

Anasthesiaequipment

Suctionequipment

Diathermyequipment

Autoclaveequipment

Monitoringequipment

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Appendix C

Explanation of Checklist

Explanation of checklist

OR lights:No shadows: The light is built by many lamps so that no shadows appear andthe light in the room is not in big contrast to the OR lights.The lights can beadjusted.

Few shadows: Few weak shadows.

Many shadows: Many shadows that are disturbing the surgery.

Temperature control:Working properly: The temperature is between 20◦ C and 23◦ C, it can beregulated, it is monitored and recorded daily using a log or electronic documen-tation and it is calibrated periodically.

Almost working properly: The temperature is between 20◦ C and 23◦ C mostof the time, it can be regulated most of the time and it is calibrated periodically.

Not working properly: The temperature is not between 20◦ C and 23◦ C,can’t be regulated and it is not calibrated periodically.

OR ventilation:Working properly: There is a filter that are keeping the aerosol level low, theair change rate is between 10 – 25 per hour1̂, the whole mechanism is alwaysworking properly, it is possible to make sure that it is working properly andcirculation and filters are checked periodically.

Almost working properly: There is a filter that are keeping the aerosol levellow, the mechanism is working properly most of the time, it is possible to makesure that it is working properly and circulation and filter are checked periodi-cally.

Not working properly: The mechanism is not working properly most of thetime, it is not possible to make sure that it is working properly and the venti-lation are not checked periodically.

Positive pressure ventilation:Working properly: The positive pressure ventilation is always working proper-ly, it is possible to measure the positive pressure, the pressure can be regulatedand someone is checking the positive pressure periodically.

Almost working properly: The positive pressure ventilation is working mostof the time, it is possible to measure the positive pressure and someone is chec-king the positive pressure periodically.

Not working properly: The positive pressure ventilation is not working mostof the time, it is not possible to measure the positive pressure and nobody ischecking the positive pressure periodically.

Humidity control:Working properly: The humidity is always between 30 – 60 % and someoneis checking the humidity periodically.

Almost working properly: The humidity is mostly between 30 – 60 % andomeone is checking the humidity periodically.

Not working properly: The humidity is not mostly between 30 – 60 % andsomeone is not checking the humidity periodically.

Room space:Enough space: There is enough space for the necessary equipment and for thepersonnel to move without causing risks.

Just enough space: There is just enough space to move and for the necessaryequipment and it may sometimes cause unnecessary risks.

Not enough space: There is not enough space for necessary equipment or forthe personnel to move and it is causing unnecessary risks.

Room order and storage:Very good order: All the medical equipment and room supplies has its ownspace and there is no disorder, such as loose cables or unnecessary items, in theroom.

Good order: There is some disorder and most equipment and room supplieshas its own space.

Bad order: There are a lot of disorder and most equipment and room suppliesdoesn’t have its own space.

Backup power supply:Working properly: The backup is working without problems.

Almost working properly: The backup is sometimes causing problems, butis working most of the time.

Not working properly: The backup is causing a lot of problems.

Washing equipment:Enough equipment: All equipment is there, including running water, a tapthat is possible to turn of with your elbow, soap, nail brush, nail clippers andsterile towels.

Needs improvement: Some of the equipment is missing but the essentials,such as soap and running water are there.

No equipment: There is no washing station in the OR.

Automatic door closers:Working properly: The doors are closing everytime without problems.

Almost working properly: The doors are closing most of the time only withsome problems.

Not working properly: The doors doesn’t close on their own or the automaticdoor closer is working poorly.

Info-links (phone, emergency bell etc.):What info-links are available in the OR?

Medical equipment:

OR tableStandard: It is possible to adjust the operating table to the proper height, itis possible to tilt it to the left and to the right during surgery, the top of theoperation table is radiolucent and the functions above is always working.

Nearly standard: It is possible to adjust the hight of the operating table, itis possible to tilt it to the left and to the right during surgery, the top of theoperation table is radiolucent and the functions above is working most of thetime.Not standard: It is not possible to adjust the hight of the operating table, itis not possible to tilt it to the left and to the right during surgery and the topof the operation table is not radiolucent.

Resuscitation equipmentStandard: The room contains a ventilator (respirator) that regulates volume,pressure and flow with heating/humidification mechanism monitor and alarm.There is a crash cart containing defibrillator, airway intubation devices, resusci-tation bag/mask and a medication box. It should be strategically located. Thereis also an intra-aortic balloon pump.

Nearly standard: The room contains a ventilator (respirator) that regulatesvolume, pressure and flow with heating/humidification mechanism monitor andalarm. There is a crash cart containing defibrillator, airway intubation devices,resuscitation bag/mask and a medication box. It should be strategically located.

Not standard: The specifics for “Nearly standard” is not fulfilled.

Anasthesia equipmentStandard: The room contains the following objects and they are working per-fectly: Infusion pump in order to deliver blood, drugs and continuous anaesthe-sia. Anaesthesia machine at the head of the operating table with monitors thatmake it possible to control the mixtures of gases. Anaesthesia cart next to theanaesthesia machine that contains the medication and equipment needed forthe anaesthesiologist. The tube that going in to the patient is always sterilizedduring operation.

Nearly standard: The room contains the following objects and they are mostlyworking perfectly: Infusion pump in order to deliver blood, drugs and continu-ous anaesthesia. Anaesthesia machine at the head of the operating table withmonitors that make it possible to control the mixtures of gases. Anaesthesia cartnext to the anaesthesia machine that contains the medication and equipmentneeded for the anaesthesiologist. The tube that going in to the patient is alwayssterilized during operation.

Not standard: The specifics for “Nearly standard” is not fulfilled.

Suction equipmentStandard: The equipment is located in the OR and is working properly.

Nearly standard: The equipment is working properly most of the time and islocated in the OR.

Not standard: The equipment is working porly or is not located in the OR.

Diathermy equipmentStandard: The diathermy equipment is mounted on a wheeled stand that istip-resistant and moves easily. Is not used near flamable agents, such as alcoholor tincture-based fluids. The cord sholud be a good length to be able to reachthe desired area without distress and should be free of knots before plugged in.

The return electrode mat should be apropriate for the patients size (child = lessthen 22 kg, adult = more then 22 kg).

Nearly standard:Nearly all the standard qualifications are fulfilled, but thereare some faults that may be a risk to the patient.

Not standard: The OR doesn’t have diathermy equipment or it is not fulfillingmany of the qualifications.

Autoclave equipmentStandard: The autoclave equipment is placed in the OR and working properly.There are protective gloves and closed toe shoes for the personnel operating theautoclave machine.

Nearly standard: The autoclave equipment is placed in or in connection tothe OR and is working properly most of the time. There are some protectiveequipment for the personnel, but not all the necessary protection.

Not standard: There is no autoclave equipment in the OR or it is workingpoorly. There is no protective equipment for the personnel.

Monitoring equipmentStandard: The OR is containing the following: Acute care physiologic monito-ring system (electrical activity of the heart via an ECG, respiratory rate, bloodpressure, body temperature etc.), puls oximeter (monitors oxygen level of theblood) and intracranial pressure monitor (can monitor pressure of fluid in thebrain of head trauma patients).

Nearly standard: The OR is missing one of the tree monitoring equipmentslisted under Standard".

Not standard: The OR is missing two or doesn’t have any of the monitoringequipments listed under Standard".

Sources:WHO, ’The surgical domain: Creating the environment. [Online][cited: may 13, 2014]’http://www.who.int/surgery/Chapter2.pdfSweat, C. (2011), ‘Chapter 1, the Design Process’, Operating Room Manual pp. 1–15Accreditation Canada Internationale, Operating rooms standards (2013)

Documents

Patient safety in operating theatres in Bangladeshkth.diva-portal.org/smash/get/diva2:739841/FULLTEXT01.pdf · Patient safety in operating theatres in Bangladesh Patients kerhet i