Patient Safety 2

ARMANDO C. CRISOSTOMO, MD, MHPEd, FPCS, FPSCRS, FPSGS PRESIDENT, PHILIPPINE COLLEGE OF SURGEONS, 2008

SURGICAL ERRORS 

A woman goes to hospital for a leg operation, and wakes up instead with a new anus.  THIS HAPPENED IN A HOSPITAL IN BAVARIA RECENTLY. 

A patient w/ hemothorax due to a SW Chest presents at ER. Surgeon places chest tube on the wrong side, no blood.  Surgeon tells patient he needs to place a second tube just like a milk can to let the blood come out. He does, blood does come out.

SURGICAL ERRORS 

A patient in Chicago, got operated on the wrong leg, and the surgeon proceeded to operate on the right leg  It ended up in court and the Judge dismissed the case because the plaintiff's arguments did not have a leg to stand on. 

The first case is true (FOX news)  The second case is true (Philippines)  The Chicago case is to lighten your burden today (joke)

GOALS OF PATIENT SAFETY  Protect

patients from harm

 Avoid/reduce  Promote

error

safe operative practices

Quality & Patient Safety Is there really a problem?  We

were educated and trained to be good and error-free - we CANNOT make a mistake!

 Errors

and mistakes come far & few - not “significant”

 “It

hasn’t happened to me!”

“Tyranny of Low Numbers”  MD’s

will have small number of errors on a personal level -> but add it up = HUGE numbers

 “Near

misses” are not counted

 Makes

board

it difficult to get everyone on

Quality & Patient Safety 

1999: Institute of Medicine (IOM) Report: “To Err is Human”

Quality & Patient Safety 1999: Institute of Medicine Report: “To Err is Human” The first public realization of the true

extent of patient harm and safety in the healthcare setting Deaths occurring from medical errors (98,000) far outnumber deaths from motor vehicle accidents (43,000), Breast Cancer (42,000) and AIDS (16,000).

Quality & Patient Safety 

Deaths from workplace injuries (6,000) are outnumbered by deaths from medication errors (7,000)



There are less deaths from adverse events occurring in nuclear reactors and the airline industry but there are more safeguards & monitoring processes in place



These industries utilize checklists, proactive reporting structure and detailed de-briefings

Why patient safety in surgery?  Surgery

= a public health issue

 Incidence

of trauma and other surgical conditions rising as a proportion of the total global burden of disease

 230

million major operations performed annually worldwide (1:25 people) 2 times more than child deliveries

Why patient safety in surgery?  Major

complications may arise in 3-16%

 Death

rate from major ORs = 0.2-10% or 7 million disabling complications and 1 million deaths each year

 Half

of complications may be avoided if certain standards of care are followed

The surgical setting is one of the most potentially hazardous of clinical environments  Traditional

OR  Ambulatory surgery center  Interventional suite  Physician’s office

Most serious potential complications  Infection  Hemorrhage  Wrong

patient/surgery/site - 1500-2500 incidents/yr. in USA (13% of adverse events, 76% - wrong site, 13% wrong patient, 11% - wrong procedure) - most common in orthopedics (68% of malpractice vs. ortho)

Potential Hazards in the OR Energy sources  Electrical

Chemical  Medications



Thermal



Antiseptics



Laser



Cements



Radiological



Intravascular dyes



Irrigating solutions

Potential Hazards . . . Biologicals 

Blood-borne pathogens



Drug resistant organisms

Equipment and Devices  Powered instruments/equip ment  Defibrillators  Tourniquets  Electrosurgical units  Positioning devices

Human Factors in Patient Safety  Communication

patterns  Institutional

culture  Staffing

patterns

“The breakdown in communication . . . Most frequently cited for contributing to wrong site surgery” JCAHO

“Poor (unsafe) care is inevitable when a complicated patient is cared for by myriad individuals who have not been trained to communicate effectively as a team.” Dr. Gerald Healy ACS President, 2008

Contributing Factors to Surgical Errors  Inadequate

communication among team

members  Incomplete review of patient health records and diagnostic studies  Traditional heirarchal and autocratic structures  Patient-related decisions made only by physicians  Rapid and frequent changes in technology  Intimidating management styles

Contributing Factors . . . Errors  Absent

or inconsistently applied rules and procedures  Fatigue  Multitasking  Time pressures/constraints  Emergency surgery  Cultural differences between patients, staff members  Staffing shortages

Contributing Factors . . . Errors  Blaming

culture  Confusing packaging of medications and supplies  Unclear instructions  Insufficient orientation and training  Patient characteristics requiring unusual set-up or requirements  Failure to include patient and family members in assessment/decision-making

“To err is human, to cover up is unforgivable, and to fail to learn is inexcusable!” Sir Liam Donaldson World Alliance for Patient Safety (2004)

Error Reduction Strategies  Reduce

reliance on memory by using checklists, protocols, computerized decision aids  Improve information access of patient records  Support contracts for new equipment and supplies providing staff education of use  Standardize procedures  Establish mechanisms to update procedure/preference cards

Error Reduction Strategies  Participate

in quality and process improvement strategies  Develop policies and procedures that address unsafe practices  Focus on safety aspects of products during selection and evaluation process  Promote safety-related clinical competency  Include patient & family in confirming identification, procedure, site

Error Reduction Strategies  Educate

employees about potential errors and how to avoid them

 Encourage

patients and family to

participate  Develop

“near miss” reporting mechanisms

“The doctor is the master of the clinical situation, but the servant of the patient.” Sir Liam Donaldson World Alliance for Patient Safety

WHO Surgical Safety Checklist 

checklist containing basic tasks to complete & safety checks to confirm prior to an operation



use of such tool will improve communication between all members of the surgical team



Support each separate step technical reports outlining evidence for the

standard its specific uses bibliography and data supporting its inclusion, implementation strategies, and implications (+/-)

8 Evaluation Sites PAHO I

Toronto, Canada

EURO

EMRO

London, UK

Amman, Jordan

WPRO I

Manila, Philippines

PAHO II

Seattle, USA

WPRO II

AFRO

Ifakara, Tanzania

SEARO

New Delhi, India

Auckland, NZ

Preliminary Pilot Site Results Site

Cases

Use of Pulse Oximeter

Time Out to Confirm Site/Pt

Objective Airway Eval

Abx @ 060 mins

IV Access >500 cc EBL

1

377

100%

100%

96%

98%

93%

2

317

97%

8.8%

74%

52%

73%

3

232

96%

100%

9.5%

34%

7%

4

496

77%

22%

45%

25%

49%

5

338

97%

50%

72%

75%

80%

6

524

99%

99%

98%

48%

32%

7

519

100%

99%

95%

78%

67%

8

446

99%

17%

0.5%

18%

73%

Total Cases 3234

Preliminary Pilot Site Results Site

1 2 3 4 5 6 7 8

Infection

Complication

Death

1.1% 1.3% 23.8% 3.4% 6.5% 9.4% 3.1% 4.0%

7.2% 5.3% 24.2% 10.08% 14% 12% 6.4% 6.3%

0.4% 0% 1.7% 3.5% 0% 2.1% 1.0% 1.3%

Total Cases 3234

WHO Checklist in PGH ORs

PGH Interim Data Cases Patient Confirmation Abx at 0-60 Minutes Airway Evaluation 2 IVs for 500cc Blood Loss Sponge Count Complication Death

PRE 496 21.77% 25.40% 46.17% 49.23%

POST 500 64.89% 55.17% 58.4% 64%

99.40% 99.8% 10.08% 7.2% 3.63% 1.4%

1st Philippine Summit on Patient Safety in Surgery (Mar 28, 2008)

1st Philippine Summit on Patient Safety in Surgery (Mar 28, 2008) Vision: A community of health professionals collaborating to save lives thru safe surgery Mission: Advocating and promoting a culture of safety in surgery thru -policy development and implementation - education and training - generation and dissemination of relevant information - collaboration and partnership

Safe Surgery Media Forum

PCS ENDORSES WHO SAFE SURGERY INITIATIVE

Signing of MOU between WHO,DOH,PHIC & PCS

Launching of Phil. Alliance for Patient Safety

Ongoing Efforts on PSS 

PCS Foundation Week activities (Sept. 7-12, 2008) - Conduct PSS summits in 11 PCS Chapters nationwide - Distribute checklist posters and manuals in all ORs, DRs  Developing research proposal on national data base (surgical vital statistics)  RP to host launching of WHO PSS Program in Asia-Pacific region

Ongoing Efforts on PSS  Multi-sectoral

task groups created

- Curriculum - Patient safety officer - Checklist implementation and monitoring - Public information and media relations - Patient safety day celebrations

SUMMARY 

Patient safety in surgery is being recognized as an important public health problem



Surgeons and the whole surgical team plays key roles in: - protecting patients from harm - avoiding/reducing error - promoting safe operative practices



PCS as lead advocate in promoting patient safety in surgery in the Philippine setting

“The public – our present and future patients – expect to be cared for by a competent surgeon who achieves quality outcomes in a safe environment.” Dr. Gerald Healy ACS President, 2008

QUALITY AND SAFETY FOR ALL! LET US ALL SAVE LIVES THRU SAFE SURGERY!

“The best way to predict

the future is to create it!” Peter