Download Surgical "Never Events"

Safety
Basic Science
December 22nd, 2009
Safety Attitudes Questionnaire (SAQ)
• I am encouraged by my colleagues to report any patient
safety concerns I may have.
• The culture in this clinical area makes it easy to learn
from the mistakes of others.
• Medical errors are handled appropriately in this clinical
area.
• I know the proper channels to direct questions regarding
patient safety in this clinical area.
• I receive appropriate feedback about my performance.
• I would feel safe being treated here as a patient.
• In this clinical area, it is difficult to discuss mistakes.
Operating Room Briefings
• preprocedure discussion of requirements,
needs, and special issues of the procedure
• locally adapted to the specific needs of the
specialty
• associated with an improved safety culture,
including increased awareness of wrongsite/wrong-procedure errors, early reporting of
equipment problems, and reduced operational
costs
Preoperative "time-out"
• Verifying the patient's identity
• Marking the surgical site
• Using a preoperative site verification process such as a
checklist
• Confirming the availability of appropriate documents and
studies before the start of a procedure
• All members of the surgical team actively communicate
and provide oral verification of the patient's identity,
surgical site, surgical procedure, administration of
preoperative medications, and presence of appropriate
medical records, imaging studies, and equipment
Surgical Specimen Errors
• Error in verbal communication and
transcription
• In one study, this type of identification
error occurred in 4.3 per 1000 surgical
specimens
• 182 mislabeled specimens per year
Sign Outs
• verbal or written communication of patient
information
• help to ensure the transfer of pertinent
information during these handoffs in
patient care, such as when taking a patient
from the OR to the recovery room, or
when a patient is being transferred from
one physician to another during shift
changes
The Surgical Care Improvement
Project Measures
• established in 2003 by a national partnership of
organizations committed to improving surgical care by
reducing the occurrence of surgical complications
• stated goal of reducing the incidence of preventable
surgical complications by 25% nationally by the year
2010
• By achieving high levels of compliance with evidencebased practices to reduce SSIs, venous
thromboembolism events, and perioperative cardiac
complications, the potential number of lives saved in the
Medicare patient population alone exceeds 13,000
annually
National Surgical Quality
Improvement Program
• credited with measuring and improving morbidity
and mortality outcomes at the VA, reducing 30day mortality rate after major surgery by 31%,
and 30-day postoperative morbidity by 45% in its
first decade
• risk-adjusted ratio of the observed to expected
outcome (focusing primarily on 30-day morbidity
and mortality) to compare the performance of
participating hospitals with their peers
The Leapfrog Group
• improving nationwide standards of health care quality,
optimizing patient outcomes, and ultimately lowering
health care costs.
• patient referral, financial incentives, and public
recognition for hospitals that practice or implement
evidence-based, health care standards.
• These include hospital use of computerized physician
order entry systems, compliance with 24-hour ICU
physician staffing, evaluation using a 30-point composite
Leapfrog Safe Practices Score, and evidence-based
hospital referral (EBHR) standards for five high-risk
operations
Surgical "Never Events"
• Surgery performed on the wrong body part
• Surgery performed on the wrong patient
• Wrong surgical procedure performed on a
patient
• Unintended retention of a foreign object in
a patient after surgery or other procedure
• Intraoperative or immediately
postoperative death in an ASA Class I
patient
Retained Surgical Items
• one case per 8000 to 18,000 operations
• one case or more each year for a typical
large hospital
• 1500 cases per year in the United States
Risk Factors for Retained Surgical Sponges
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Emergency surgery
Unplanned changes in procedure
Patient with higher body-mass index
Multiple surgeons involved in same operation
Multiple procedures performed on same patient
Involvement of multiple operating room
nurses/staff members
• Case duration covers multiple nursing "shifts"
Surgical Counts
• "falsely correct count," in which a count is
performed and declared correct when it is
actually incorrect, occurred in 21 to 100%
of cases in which a retained surgical item
was found
What is the medical definition
for a retained surgical sponge?
Gossypiboma
Wrong-Site Surgery
• Wrong-site surgery is any surgical procedure
performed on the wrong patient, wrong body
part, wrong side of the body, or wrong level of a
correctly identified anatomic site.
• ranging from one in 112,994 cases to one in
15,500 cases
• Communication errors are the root cause in
more than 70% of the wrong-site surgeries
reported to the Joint Commission
Risk-Factors
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time pressure
emergency surgery
abnormal patient anatomy
incomplete preoperative assessment
inadequate procedures in place to verify the
correct surgical site
• organizational culture that lacks teamwork or
reveres the surgeon as someone whose
judgment should never be questioned
Common Causes of Lawsuits in Surgery
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Positional nerve injury
Common bile duct injury
Failure to diagnose or delayed diagnosis
Failure to treat, delayed treatment, or wrong
treatment
Inadequate documentation
Inappropriate surgical indication
Failure to call a specialist
Cases resulting in amputation/limb loss