Surgical Safety & Safer surgery

Surgical Safety&

Safer surgery

Dr. Md. Majedul IslamRegistrar

Department of SurgeryEnam Medical College Hospital

Introduction

Safety is everybody’s business. According the Hippocratic oath from 5th century :

“ Never do harm to anyone”

Safer Surgery can be defined as a reduction in avoidable harm to a surgical patient

Surgery It is a part of medical specialty that uses operative

manual and instrumental technique on a patient to investigate or treat a pathological condition.

Surgical team:1. Surgeon2. Surgeon’s assistance3. Anesthetist4. Scrub nurse5. Scouting nurse6. Surgical technologist

Surgical period Time or duration when patient

admitted and discharge after completion of surgery.

So, surgical safety has broadly included in different phases:

1. Preoperative(Diagnosis, investigation)2. Per operative3. Postoperative(Up to discharge)

Some definition

1. Adverse events: An incident which result in harm to the patient.

2. Near Miss: An incident which could resulted in unwanted harm but did not.

3. No-harm events: An incident that occur and reach to the patient but result in no injury.

How safe is SurgeryAn article in the Gurdian newspaper UK

in March 2013 claimed that “five worst medical” nightmares a Pt faces, three related to surgery:

1. Wrong site surgery2. Wrong patient surgery3. Retained instruments and swabsThe rate of harm in surgical patient is

unknown but probably occur in about 10% surgical patient, though much of this harm will be minor.

Why do patients suffer avoidable harm1. Patients themselves.2. Healthcare professional3. System failure.4. Medical complexity

Why do patients suffer avoidable harm(contd.)

Patients Themselves1. A variety of presentation.2. Differing co-morbidities3. Differing response to treatment4. Patients are reluctant to speak up.5. Refuse to co-operate6. Hide and seek


Healthcare professional1. Inadequate Pt assessment(delay or error in

Diagnosis)2. Failure to use or interpret appropriate test3. Error in performance of an operation and test.4. Inadequate monitoring or follow-up.5. Deficient training or experience6. Fatigue, overwork or time pressure.7. Personal or psychological factor i.e. drug abuse

or depression.8. Lack of recognition of the danger of medical

errors.


System failure1. Poor communication between healthcare

provider.2. Inadequate staffing level3. Overreliance on investigation4. Lack of coordination at handover5. Drug similarities.6. Equipment failure due to lack of skilled

operators.7. Inadequate system to report and review

patient safety incident.


Medical complexity1. Advance and new

technologies(laparoscopic, robotic surgery)

2. Potent drug and their side effects and interaction.

3. Working environment- Surgical ICU, HDU and Operation theatre

Surgical errors

Surgery is one of the most complex health intervention to deliver. More than 100 million people worldwide require surgical treatment every year for different reason.

Great Professor of Surgery Sir Alfred Cuschieri and other describes surgical errors in different categories that committed by the surgeons during care of the Patients.

Sir Alfred Cuschieri describes the errors are

1. Diagnosis and management errors.2. Resuscitation errors.3. Prophylaxis errors.4. Prescription and parenteral

administration errors.5. Situation awareness, identification

and teamwork errors.6. Technical and operative errors.

Situation awareness, identification and teamwork errors.

1. Wrong patient in the operation theatre.

2. Surgery performed in the wrong side or site

3. Wrong procedure4. Failure to communicate changes in

the patient condition.5. Disagreement about proceeding.6. Retained instruments or swabs.

Technical and operative errors

1. Cognitive error of judgment.2. Procedural(Steps of surgery not

followed)3. Executional (damage)4. Misinterpretation.5. Missed iatrogenics injury.

Several studies have shown that majority of surgical errors(53-70 per cent) occur outside the operating theatre, before or after the surgery.

CT scan showing an heterogeneous and low density mass, with peripheral calcifications, measuring 7.4 cm diameter, localized on left hypochondrium

How can surgery be made “SAFER”

1. Right surgeon, Right place, Right time: Right surgeon- a surgeon of adequate

training and experience.Trained surgeons require updating in current

techniques and training in new one.For trainee: described later…..

Right time is applicable for emergency surgery…

How can surgery be made “SAFER” contd.

2. Standardisation of process: It based on research evidence or best practice i.e.

Pre-op investigation Optimization of co morbidity Optimization of malnutrition DVT prophylaxis Antibiotic prophylaxis Management of pt require emergency

surgery


3. Communicating openly with patients andtheir carers and obtaining consent:

Details and uncertainties of the diagnosis The purpose and details of the proposed surgery Known possible side effects and potential complications The likely prognosis Other options for treatment, including the option not to treat Explanation of the likely benefits and probabilities of success

for each option The name of the doctor who will have overall responsibility A reminder that the patient can change his or her mind at

any time


3 Surgical safety checklist : In 2008, the World Health Organization (WHO) published guidelines of recommended practices to reduce the rate of preventable surgical complications and death worldwide)

WHO Surgical Safety Checklist: UK process

Step 1: Prelist briefingStep 2: Sign in(Before induction of anaesthesia)Step 3: Time out(Before skin incision)Step 4: Sign out(Before patient leaves operating room)Step 5: Postlist debriefing

WHO Surgical Safety Checklist

What should be follow strictly in theatre

The WHO checklist should be completed for every patient coming to theatre

Appropriate antibiotic and venous thromboembolism (VTE) prophylaxis, monitoring, careful positioning, temperature, glycaemic and infection control

The operating theatre environment should be optimised with regard to lighting, ventilation, humidity and temperature

What should be follow strictly in theatre, Contd.

Additional equipment, such as diathermy and tourniquets, should be used while recognising their potential complications

Theatre etiquette including scrubbing, prepping and draping and personnel movement is designed to minimise crossinfection


4. Learning from incidents: by reporting, analysis to reduce further mistakes but……

Unfortunately this is not very effective because of • Many incidents are not reported• Number are more so difficult to give priorities• Not always correct analysis • Difficulty in implementing action

• Complaints from Pt also another source of learning but it may be often for harassment.


5. Prescribing safely: Unfortunately, edication errors are common and their many causes include:

• poor assessment or inadequate knowledge of patients and their clinical conditions;

• inadequate knowledge of the medications;• dosage calculation errors;• illegible hand writing;• confusion regarding the name or the mixing

up of medications.

What about developed country

Regulating and licensing of physicians and healthcare institutions;

developing and adopting policies for patient safety and quality improvement;

providing patient safety education rogrammes; instituting national clinical audits; reporting (and learning from) adverse events; setting up agencies to resolve concerns about

the practice of doctors by providing case and incident management services

What about developing country The probability of a patient being harmed in

hospital is higher with, for example, the risk of healthcare-associated infection being as much as 20 times higher than in developed countries.

At least 50 per cent of medical equipment in developing countries is unusable or only partly usable and often the equipment is not used due to lack of parts or necessary skills.

Lack of monitoring in training programme Lack of accountability, corruption,

malpractice

Surgical Assistant Surgical assistants are frequently surgeons

in training. They are therefore in theatre to help the

senior surgeon and to learn as much as possible.

Role: 1. Preparation. review the anatomy and

the operation before surgery to anticipate and understand the actions of the senior surgeon. They should start scrubbing first, having checked that the patient is ready for theatre.

Surgical Assistant Role Contd. 2. Training: Trainees should write important

steps of proposed operation in brief on a board in the operating theatre.

3. At surgery: should try to provide the surgeon with the best access possible by placing and holding retractors and showing the surgeon the field where they are working. Instruments and retractors should always be asked for by name.

4. After surgery: The assistant should help transfer the patient safely off the table and may write the operative note. They should keep a log of all operations attended and what they have learnt from each case.

SURGEONISM All bleeding eventually stops. A very bold surgeon is one who realise that his pt takes

all the risk. It takes 5 years to know when to operate, 20 years to

learn when not to. There are only 3 rules to a surgeons life : eat when u can;

sleep when u can; don’t screw with pancrease. Don’t look for for things you don’t want to find The lesser the indication the greater will be the

complication Surgery like making love , should be done gently with

adequate exposure. Pyar aur surgeon kabhi jukhta nahi. Never rely on investigation it is always better to open

and see if confused.

Sir Alfred CuschieriFather of laparoscopic Surgery

Health & Medicine

Surgical Safety & Safer surgery