Safe Surgery with Professor Cliff Hughes:

How is your Appetite for Risk?

Prof Cliff Hughes AO October 2016

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Solo Surgeon or Team Player?

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Railway tracks

Rail

Sleeper Ballast

Bed

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The Quality Journey:

•Even if you're on the right track, you’ll get run over if you just sit there.

• Will Rogers, Humourist

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Report of Officers of the Railway Department 1842

• Class 1 (Beyond the control of passengers)

– -29 accidents, 24 killed, 72 injured

• Class 2 (own negligence or misconduct)

– 36, 17 20

• Class 3* (“Servants of the company”)

– 60, 20 36

– * note this return is incomplete, no requirement to report accidents which are not of a public nature

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Vision!

• “So I am called eccentric for saying in public: that Hospitals, if they wish to be sure of improvement,

• Must find out what their results are. • Must analyse their results, to find their strong and weak points. • Must compare their results with those of other hospitals … • Must welcome publicity not only of their successes, but for their

errors. • Such opinions will not be eccentric a few years hence” • Ernest Amory Codman, 1917 ( 1869-1940, Surgeon, USA)

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Tracks and wheels

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Where is the point of contact?

Not on the side But on the top centre

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Tracks and wheels

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Simplicity

•Find the point of contact

•Minimum is optimum

•Should follow natural rules - Human Factors

•Should be standardised

•Should have back up protection and safe guards

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Blood Transfusion Improvement Collaborative

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Proportion of red cell units (dose) transfused in

rural base hospitals which are either above or

below the NSW State average (2005-2006)(calculated as casemix adjusted relative use index: source

data CEC red cell data linkage project)

-20

-10

0

10

20

30

40

50

60

70

1 2 3 4 5 6

Hospital code

%

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Haemoglobin g/L 70

80

90

100 60

50

40

110 120 130 140

Benefit > Risk

Risk > Benefit

Within this region

individual patient factors

determine transfusion

threshold

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Sustainability

•Must be the easy way

•Must be automatic

•Must be follow natural rules

•Should be standardised

•Should have back up protection and warnings

CF Hughes 9th April

2008

Granville: 18th January 1977

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Granville: 18th January 1977

• 83 dead

• 900 rescuers

• 5000 sightseers • “I don’t mean to sound cynical but I don’t think it did much more than change some specific safety

standards involving bridges and trains’

• “ my family caught the train to and through Sydney the next day. Do you think that a train crash has changed anything?”

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From the track to the bed

• Adverse events occur during “normal” activity

• Only a few see it coming

• It can happen when the rules are being obeyed

• Practiced responses will save lives

• Cynicism remains the enemy

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Glenbrook: 2 December 1999

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Glenbrook: 2 December 1999

• 7 dead

• 50 injured, 8 critical

• Faulty signals

• No radio or telephone contact

• Safe working rules deliberately broken

• Safety audit promised!?!

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From the track to the bed

• Ensure warning signs are heeded

• Ensure communication is possible at all times

• No one knows better!

• Safety audits show safety and warn of danger ahead

• Disasters show negligence and point to dangers past

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Waterfall: 31 January 2003

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Liverpool and Manchester Railway 15 September 1830

•Stephenson’s Rocket

•First Passenger train

•First railway accident

•First railway ambulance

•First railway fatality

•W Huskisson MP

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Waterfall: 31 January 2003

• 7 dead

• Out of telephone range?

• Driver incapacity

• Safety mechanisms failed to work

• Underdeveloped safety culture

• No dataloggers installed

• Reliance on accident trends

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From the track to the bed

• Accumulate real time data

• Safety measures must be in place NOW

• Communications must be working

• Hazards must be identified

• Training is essential

• Resourcing is necessary part of a safety culture

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Blackheath: 15 March 1990

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Blackheath: 15 March 1990

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From the track to the bed

• Broken guidelines are dangerous

• Persistence is vital

• Reporting mechanism must be available

• Anyone can help

• Incentives needed

• Near misses are invaluable lessons

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Thanks for Listening