Effectiveness of the surgical safety checklist in correcting errors: a literature review applying Reason's Swiss cheese model

Never events in plastic surgery: An analysis of surgical burns and medical malpractice litigation

INTRODUCTION

Burns and fires in the operating room are a known risk and their prevention has contributed to many additional safety measures. Despite these safeguards, burn injuries contribute significantly to the medical malpractice landscape. The aim of the present study is to analyze malpractice litigation related to burn and fire injuries in plastic and reconstructive surgery, identify mechanisms of injury, and develop strategies for prevention.

METHODS

The Westlaw and LexisNexis databases were queried for jury verdicts and settlements in malpractice lawsuits related to burn and fire injuries that occurred during plastic surgery procedures. The Boolean terms included "burn & injury & plastic", "fire & injury & "plastic surg!"" in Westlaw, and "burn & injury & "plastic surg!"", "fire & injury & "plastic surg!"" in LexisNexis.

RESULTS

A total of 46 cases met the inclusion criteria for this study. Overheated surgical instruments and cautery devices were the most common mechanisms for litigation. Plastic surgeons were defendants in 40 (87%) cases. Of the included cases, 43% were ruled in favor of the defendant, while 33% were ruled in favor of the plaintiff. Mishandling of cautery devices 6 (13%), heated surgical instruments 6 (13%), and topical acids 2 (4%) were the most common types of errors encountered.

CONCLUSION

Never events causing burn injury in plastic and reconstructive surgery are ultimately caused by human error or neglect. The misuse of overheated surgical instruments and cauterizing devices should be the focus for improving patient safety and reducing the risk of medical malpractice. Forcing functions and additional safeguards should be considered to minimize the risk of costly litigation and unnecessary severe harm to patients.

Going beyond compliance: A qualitative study of the practice of surgical safety checklist

BACKGROUND

The World Health Organization Surgical Safety Checklist (SSC) is a tool designed to enhance team communication and patient safety. When used properly, the SSC acts as a layer of defence against never events. In this study, we performed secondary qualitative analysis of operating theatres (OT) SSC observational notes to examine how the SSC was used after an intensive SSC re-implementation effort and drew on relevant theories to shed light on the observed patterns of behaviours. We aimed to go beyond assessing checklist compliance and to understand potential sociopsychological mechanisms of the variations in SSC practices.

METHODS

Direct observation notes of 109 surgical procedures across 13 surgical disciplines were made by two trained nurses in the OT of a large tertiary hospital in Singapore from February to April 2022, three months after SSC re-implementation. Only notes relevant to the use of SSC were extracted and analyzed using reflexive thematic analysis. Data were coded following an inductive process to identify themes or patterns of SSC practices. These patterns were subsequently interpreted against a relevant theory to appreciate the potential sociopsychological forces behind them.

RESULTS

Two broad types of SSC practices and their respective sub-themes were identified. Type 1 (vs. Type 2) SSC practices are characterized by patience and thoroughness (vs. hurriedness and omission) in carrying out the SSC process, dedication and attention (vs. delegation and distraction) to the SSC safety checks, and frequent (vs. absence of) safety voices during the conduct of SSC. These patterns were conceptualized as safety-seeking action vs. ritualistic action using Merton's social deviance theory.

CONCLUSION

Ritualistic practice of the SSC can undermine surgical safety by creating conditions conducive to never events. To fully realize the SSC's potential as an essential tool for communication and safety, a concerted effort is needed to balance thoroughness with efficiency. Additionally, fostering a culture of collaboration and collegiality is crucial to reinforce and enhance the culture of surgical safety.

Facilitators and barriers to the implementation of surgical safety checklist: an integrative review

Surgical procedures pose an immense risk to patients, which can lead to various complications and adverse events. In order to safeguard patients' safety, the World Health Organization initiated the implementation of the Surgical Safety Checklist (SSC) in operating theatres worldwide. The aim of this integrative review was to summarize and evaluate the use and implementation of SSC, focusing on facilitators and barriers at the individual, professional, and organizational levels. This review followed closely the integrative review method by Whittemore and Knafl. An English literature search was conducted across three electronic databases (PubMed, CINAHL, and EMBASE) and other hand search references. Keywords search included: 'acute care', 'surgical', 'adult patients', 'pre-operative', 'intra-operative', and 'post-operative'. A total of 816 articles were screened by two reviewers independently and all articles that met the pre-specified inclusion criteria were retained. Data extracted from the articles were categorized, compared, and further analysed. A total of 34 articles were included with the majority being observational studies in developed and European countries. Checklists had been adopted in various surgical specialities. Findings indicated that safety checklists improved team cohesion and communication, resulting in enhanced patient safety. This resulted in high compliance rates as healthcare workers expressed the benefits of SSC to facilitate safety within operating theatres. Barriers included manpower limitations, hierarchical culture, lack of staff involvement and training, staff resistance, and appropriateness of checklist. Common facilitators and barriers at individual, professional, and organizational levels have been identified. Staff training and education, conducive workplace culture, timely audits, and appropriate checklist adaptations are crucial components for a successful implementation of the SSC. Methods have also been introduced to counter barriers of SSC.

Surgical safety checklists in UK veterinary practice: Current implementation and attitudes towards their use

BACKGROUND

Surgical safety checklist (SSC) use benefits veterinary patients, but endorsement and implementation are essential for these benefits to be observed.

METHODS

A cross-sectional survey assessed UK veterinary professionals' attitudes towards and usage of SSCs and identified factors associated with poorer attitude or failure to use SSCs.

RESULTS

Of 513 respondents, 70% used SSCs. Of these, 87.1% used SSCs for every surgical procedure, 19.1% adapted SSCs for different procedures and 61.1% had a standard operating procedure detailing how to use SSCs. Attitudes towards SSC use were favourable, with increased positive attitude associated with employing at least one registered veterinary nurse with a post-qualifying qualification (p < 0.001), current SSC use (p < 0.001), undertaking self-directed reading (p = 0.033) or completing SSC-relevant post-qualification continuing professional development (p = 0.005). Factors associated with veterinary practices not using SSCs included Practice Standards Scheme (PSS) non-membership (odds ratio [OR] 2.0, 1.1-3.4), no RCVS hospital status (OR 1.9, 1.1-3.5) or being a mixed first-opinion veterinary practice (OR 2.4, 1.2-5.0).

LIMITATIONS

Study limitations include sampling methodology and non-validated attitudinal scale usage.

CONCLUSION

Most respondents used SSCs. Familiarity, education and the RCVS PSS were associated with improved uptake and attitudes, but mixed practice was associated with reduced usage.

Risk patterns of consecutive adverse events in airway management: a Bayesian network analysis

BACKGROUND

Minor adverse airway events play a pivotal role in the safety of airway management. Changes in airway management strategies can reduce such events, but the broader impact on airway management remains unclear.

METHODS

Minor, frequently occurring adverse airway events were audited before and after implementation of changes to airway management strategies. We used two Bayesian networks to examine conditional probabilities of subsequent airway events and to compute the likelihood of certain events given that certain previous events occurred.

RESULTS

Independent of sex, age, and American Society of Anesthesiologists physical status, targeted changes to airway management strategies reduced the risk of a first event. Obese patients were an exception, in whom no risk reduction was achieved. Frequently occurring event sequences were identified, for example the most likely event to follow difficult bag-mask ventilation was a Cormack-Lehane grade ≥3, with a risk of 14.3% (95% credible interval [CI], 11.4-17.2%). An impact of the targeted changes was detected on the likelihood of some event sequences, for example the likelihood of no consecutive event after a tracheal tube-related event increased from 43.3% (95% CI, 39.4-47.6%) to 56.4% (95% CI, 52.0-60.5%).

CONCLUSIONS

Identification of risk patterns and typical structures of event sequences provides a clinically relevant perspective on airway incidents. It further provides a means to quantify the impact of targeted airway management changes. These targeted changes can influence some event sequences, but overall, the benefit results from the cumulative effect of improvements in multiple events. Targeted airway management changes with knowledge of risk patterns and event sequences can potentially further improve patient safety in airway management.

CLINICAL TRIAL REGISTRATION

NCT02743767.

Operating Room Nurses' Understanding of Their Roles and Responsibilities for Patient Care and Safety Measures in Intraoperative Practice

Introduction

Surgical care has been a vital part of healthcare services worldwide. Several patient safety measures have been adopted universally in the operating room (OR) before, during, and following surgical procedures. Despite this, errors or near misses still occur. Nurses in the OR have a pivotal role in the identification of factors that may impact patient safety and quality of care. Therefore, exploring the OR nurses' understanding of their roles and responsibilities for patient care and safety in the intraoperative practice, which could lead to optimal patient safety, is essential.

Objective

This study explored the understanding of OR nurses regarding their roles and responsibilities for patient care and safety measures in the intraoperative practice.

Methods

The study was conducted in one of the tertiary care hospitals in the United Arab Emirates. Qualitative, descriptive, exploratory research design was utilized. The data were collected using semi-structured face to face interviews. Purposive sampling included eight nurses. Data analysis was performed following Colaizzi's seven-step strategy.

Results

Seven emerging themes were identified. The main themes are: patient safety, preoperative preparation, standardization of practice, time management, staffing appropriateness, staff education and communication, and support to the patient in the OR.

Conclusion

OR nurse leaders may take into consideration the current findings as a reference for quality improvement projects in the hospital, considering the specific characteristics of each local setting. Although the participants consider that the environment is safe and the quality of care is high in the study setting, there is still room for improvement on workflows and processes. OR workflow should be improved especially by addressing the potential patient safety issues.

The impact and prevention of systemic and diagnostic errors in surgical malpractice claims in Japan: a retrospective cohort study

The Surgical Patient Safety System (SURPASS) has been proven to improve patient outcomes. However, few studies have evaluated the details of litigation and its prevention in terms of systemic and diagnostic errors as potentially preventable problems. The present study explored factors associated with accepted claims (surgeon-loss). We retrospectively searched the national Japanese malpractice claims database between 1961 and 2017. Using multivariable logistic regression models, we assessed the association between medical malpractice variables (systemic and diagnostic errors, facility size, time, place, and clinical outcomes) and litigation outcomes (acceptance). We evaluated whether or not the factors associated with litigation could have been prevented with the SURPASS checklist. We identified 339 malpractice claims made against general surgeons. There were 159 (56.3%) accepted claims, and the median compensation paid was 164,381 USD. In multivariable analyses, system (odds ratio, 27.2 95% confidence interval 13.8-53.5) and diagnostic errors (odds ratio 5.3, 95% confidence interval 2.7-10.5) had a significant statistical association with accepted claims. The SURPASS checklist may have prevented 7% and 10% of the accepted claims and systemic errors, respectively. It is unclear what proportion of accepted claims indicated that general surgeon loses should be prevented from performing surgery if the SURPASS checklist were used. In conclusion, systemic and diagnostic errors were associated with accepted claims. Surgical teams should adhere to the SURPASS checklist to enhance patient safety and reduce surgeon risk.

Effect of the Surgical Safety Checklist on the incidence of adverse events: contributions from a national study

OBJECTIVE

the study evaluated the effect of using the safe surgery checklist (CL) on the incidence of adverse events (AE).

METHODS

cross-sectional and retrospective research with 851 patients undergoing surgical procedures in 2012 (n=428) and 2015 (n=423), representing the periods before and after CL implantation. The AE incidences for each year were estimated and compared. The association between the occurrence of AE and the presence of CL in the medical record was analyzed.

RESULTS

a reduction in the point estimate of AE was observed from 13.6% (before using the CL) to 11.8% (with the use of the CL). The difference between the proportions of AE in the periods before and after the use of CL was not significant (p=0.213). The occurrence of AE showed association with the following characteristics: anesthetic risk of the patient, length of stay, surgery time and classification of the procedure according to the potential for contamination. Considering the proportion of deaths, there was a significant reduction in deaths (p=0.007) in patients whose CL was used when compared to those without the use of the instrument. There was no significant association between the presence of CL and the occurrence of AE. It was concluded that the presence of CL in the medical record did not guarantee an expected reduction in the incidence of AE.

CONCLUSION

however, it is believed that the use of the instrument integrated with other patient safety strategies can improve the safety/quality of surgical care in the long term.

Surgical team perceptions of the surgical safety checklist in a tertiary hospital in Jordan: a descriptive qualitative study

Purpose

The purpose of this paper is to explore the perceptions of operating room staff towards the use of the World Health Organization Surgical Safety Checklist in a tertiary hospital in Jordan.

Design/methodology/approach

This was a qualitative descriptive study. Semi-structured interviews were conducted with a purposeful sample of 21 healthcare staff employed in the operating room (nurses, residents, surgeons and anaesthesiologists). The interviews were conducted in the period from October to December 2021. Thematic analysis was used to analyse the data.

Findings

Three main themes emerged from data analysis namely compliance with the surgical safety checklist, the impact of surgical safety checklist, and barriers and facilitators to the use of the surgical safety checklist. The use of the checklist was seen as enabling staff to communicate effectively and thus to accomplish patient safety and positive outcomes. The perceived barriers to compliance included excessive workload, congestion and lack of training and awareness. Enhanced training and education were thought to improve the utilization of the surgical safety checklist, and help enhance awareness about its importance.

Originality/value

While steps to utilize the surgical safety checklist by the operation room personnel may seem simple, the quality of its administration is not necessarily robust. There are several challenges for consistent, complete and effective administration of the surgical safety checklist by the surgical team members. Healthcare managers must employ interventions to eliminate barriers to and offer facilitators of adherence to the application of the surgical safety checklist, therefore promoting quality healthcare and patient safety.

Understanding the "Swiss Cheese Model" and Its Application to Patient Safety

ABSTRACT

This article reviews several key aspects of the Theory of Active and Latent Failures, typically referred to as the Swiss cheese model of human error and accident causation. Although the Swiss cheese model has become well known in most safety circles, there are several aspects of its underlying theory that are often misunderstood. Some authors have dismissed the Swiss cheese model as an oversimplification of how accidents occur, whereas others have attempted to modify the model to make it better equipped to deal with the complexity of human error in health care. This narrative review aims to provide readers with a better understanding and greater appreciation of the Theory of Active and Latent Failures upon which the Swiss cheese model is based. The goal is to help patient safety professionals fully leverage the model and its associated tools when performing a root cause analysis as well as other patient safety activities.

Development and Validation of a Questionnaire of the Perioperative Nursing Competencies in Patient Safety

(1) Background: This research presents the CUCEQS© (Spanish acronym for Questionnaire of Perioperative Nursing Safety Competencies), which evaluates the perception of perioperative nurses about their competencies related to surgical patient safety. The aim of the present study was to design, validate, and analyze the psychometric properties of the CUCEQS©. (2) Methods: We devised an instrumental, quantitative, and descriptive study divided into two phases: in the first, the questionnaire was designed through a Delphi method developed by perioperative nurses and experts in patient safety. In the second, the reliability, validity, and internal structure of the tool were evaluated. (3) Results: In the first phase, the items kept were those that obtained a mean equal to or higher than four out of five in the expert consensus, and a Content Validity Index higher than 0.78. In the second phase, at the global level, a Stratified Cronbach's Alpha of 0.992 was obtained, and for each competency, Cronbach's Alpha values between 0.81 and 0.97 were found. A first-order confirmatory factor analysis of the 17 subscales (RMSEA 0.028, (IC 90% = 0.026-0.029) and its observed measures was performed for the 164 items, as well as a second-order analysis of the four competencies (RMSEA = 0.034, (IC90% = 0.033-0.035). (4) Conclusions: The questionnaire is a valid tool for measuring the perceived level of competency by the perioperative nurses in surgical patient safety. This is the first questionnaire developed for this purpose, and the results obtained will facilitate the identification of areas to be improved by health professionals in patient safety.

Efeito do Checklist de cirurgia segura na incidência de eventos adversos: contribuições de um estudo nacional

RESUMO Objetivo: o estudo objetivou avaliar o efeito da utilização do checklist (CL) de cirurgia segura na incidência de eventos adversos (EA). Método: pesquisa transversal e retrospectiva com 851 pacientes submetidos a procedimentos cirúrgicos nos anos de 2012 (n=428) e 2015 (n=423), representando os períodos antes e após a implantação do CL. As incidências de EA para cada ano foram estimadas e posteriormente comparadas. Também foi analisada a associação entre a ocorrência do EA e a presença do CL no prontuário. Resultados: observou-se uma redução na estimativa pontual de EA de 13,6% (antes do uso do CL) para 11,8% (com a utilização do CL). No entanto, a diferença entre as proporções de EA nos períodos antes e após a utilização do CL não foi significativa (p=0,213). A ocorrência do EA mostrou associação significativa às seguintes características: risco anestésico do paciente, tempo de internação, tempo de cirurgia e classificação do procedimento segundo o potencial de contaminação. Considerando a proporção de óbitos ocorridos nas amostras, observou-se uma redução significativa de mortes (p=0,007) em pacientes cujo CL foi utilizado quando comparados aqueles sem o uso do instrumento. Não foi verificada associação significativa entre a presença do CL no prontuário e a ocorrência do EA de forma geral. Conclusão: a presença do CL no prontuário não garantiu uma redução esperada na incidência de EA. No entanto, acredita-se que o uso do instrumento integrado às demais estratégias de segurança do paciente possa melhorar a segurança/qualidade da assistência cirúrgica em longo prazo.

Compliance with the Surgery Safety Checklist: An Update on the Status

WHO has recommended the implementation of the Surgery Safety Checklist (SSC) to reign in often simple logistic errors that lead to numerous complications, some of them being fatal, in the perioperative period. This study aims to discuss doubts presented in the medical literature concerning the effectiveness of SSC in the currently existing form. The article is based on the literature search performed in PubMed using the command phrase "Surgery Safety Checklist". The search yielded 1,476 articles up to March 2021. Out of this group, we selected 811 articles for further detailed analysis. The selection was based on the meritorious SSC-related topicality and scrutinized content of the articles. Out of these articles, we identified 59 studies that specifically raised the issue of the effectiveness of SSC use in its current form, which we discussed herein in detail. The review distinctly indicates that the SSC reduces perioperative complications including fatalities. However, there are issues reported with the itemized content of the checklist that hardly corresponds to the diverseness of patients' conditions and operating room settings. Further, it is unclear if a reduction in the complications stems from the use of SSC or the algorithms for performing procedures it contains. The consensus arises that SSC should be periodically updated so that it would catch up with the advances in medical knowledge and the emerging technologies, which would safeguard the SSC from becoming just another paperwork nuisance for the operating room staff.

Optimisation of airway management strategies: a prospective before-and-after study on events related to airway management

BACKGROUND

Poor medical outcomes often result from series of minor events. The present study assessed events related to airway management to determine whether targeted changes to departmental strategies for airway management can reduce the incidence.

METHODS

This prospective before-and-after study was performed with ethics committee approval and written informed consent from patients. Major and minor events related to airway management were prospectively recorded for 9 weeks. After implementation of changes to departmental strategies for airway management, events were again prospectively recorded over 9 weeks. Primary outcome was number of cases with events. Secondary outcomes were various predefined events.

RESULTS

At study baseline, 3668 cases and at follow-up 3786 cases were assessed. Cases with events decreased from 566 (15.4%) to 433 (11.4%) (risk ratio [RR]=0.74; 95% confidence interval [CI], 0.66-0.83; P<0.01). As secondary outcomes, the following events decreased: Cormack-Lehane grade 3 or 4 (4.3-2.9%; RR=0.67; 95% CI, 0.52-0.85; P<0.01); difficult bag-mask ventilation (3.8-2.7%; RR=0.69; 95% CI, 0.54-0.89; P<0.01); hypoxaemia (3.8-2.9%; RR=0.75; 95% CI, 0.59-0.96; P=0.03); unplanned use of special equipment (3.2-2.0%; RR=0.62; (95% CI, 0.47-0.83; P<0.01); oesophageal intubation (1.3-0.8%; RR=0.61; 95% CI, 0.39-0.96; P=0.03); bleeding (0.8-0.2%; RR=0.30; 95% CI, 0.14-0.63; P<0.01); insufficient spontaneous breathing (0.3-0.0%; RR=0.09; 95% CI, 0.01-0.68; P<0.01); communication errors (0.1-0.0%; RR=0; 95% CI, 0-NA; P=0.03).

CONCLUSIONS

Implementation of changes to departmental strategies for airway management significantly reduced cases with events related to airway management. Analysis of events and implementation of strategies that specifically target identified issues might be key to improving airway management.

CLINICAL TRIAL REGISTRATION

NCT02743767.

Anesthesia screen use may impact operating room communication practices in otolaryngology

OBJECTIVES

Failures in communication are a leading contributor to medical error. There is increasing attention on cultivating robust communication practices in the Operating Room (OR) to mitigate against patient injury and optimize efficient patient care. Few studies have evaluated how surgical equipment may introduce barriers to team dynamics.

DESIGN

We conducted a pilot observational study to examine the relationship between anesthesia screen drapes (which are used inconsistently) and the frequency of verbal exchanges between surgical and anesthesia members. 25 procedures spanning various procedures in Otolaryngology were covertly observed, 12 of which employed a screen. Verbal exchanges were recorded across three stages of the surgery: pre-procedure (before the draping), procedure (drapes placed throughout) and post-procedure (after the removal of the draping). Speaker and content of the exchange was noted as well as various features about the procedure.

RESULTS

Decreases in rates of exchanges were most pronounced during the procedure stage, although they did not reach significance on T-testing (p = 0.0719). After controlling for attending, table orientation and number of professionals, regression analysis did reveal a statistically significant decrease in rates of verbal exchanges during the procedure in the presence of the anesthesia screen (7.17 (± 6.33) versus 2.23 (± 1.00), p = 0.0318). Differences were also significant among surgeon-initiated and patient-care-related exchanges (p = 0.0168 and p = 0.0432, respectively). Decreases in anesthesiologist-initiated and non-clinical exchanges did not reach significance (p = 0.1530 and p = 0.5120, respectively).

CONCLUSION

This pilot study suggests that anesthesia screens may negatively impact communication practices in the OR.

Correlations of Radiographic and Endoscopic Observations in Subglottic Stenosis

OBJECTIVE(S)

Subglottic stenosis (SGS) represents a constellation of diverse pathologic processes that ultimately lead to narrowing of the subglottic region and can produce significant morbidity. Existing endoscopic and radiographic assessments may not be consistent in practice.

METHODS

Severity of stenosis was evaluated and reported using the Cotton-Myer classification system from 33 endoscopic procedures from 32 unique subjects. Radiographic imaging within the preceding 3 month period was subsequently reviewed and narrowing was measured by a blinded radiologist. Degree of stenosis was reported as a percentage in 30 out of 33 endoscopic evaluations and subsequently compared to radiographically determined percentage of stenosis. Statistical analyzes were conducted to evaluate concordance between endoscopic and radiographic assessments.

RESULTS

About 45.5% (15/33) of the evaluations were in agreement using Cotton-Myer scoring, while 27.3% (9/33) were discrepant by 1 grade and 27.3% (9/33) by 2 grades. Correlation of degree of stenosis as a percentage using Spearman (coefficient: 0.233, P-value: .214) and Pearson (coefficient: 0.138, P-value: .466) methods demonstrated very weak relationships. Radiographic scoring did not predict endoscopic classification to a significant degree using mixed effects regression.

CONCLUSIONS

Radiographic and endoscopic grading of subglottic stenosis may not be reliably concordant in practice.

Self-Learning Methodology in Simulated Environments (MAES©) as a Learning Tool in Perioperative Nursing. An Evidence-Based Practice Model for Acquiring Clinical Safety Competencies

Background: The self-learning Methodology in Simulated Environments (Spanish acronym: MAES©, (Murcia, Spain) is a type of self-directed and collaborative training in health sciences. The objective of the present study was to compare the level of competence of postgraduate surgical nursing students in the clinical safety of surgical patients, after training with the MAES© methodology versus traditional theoretical–practical workshops, at different points in time (post-intervention, after three months, six months post-intervention, and at the end of the clinical training period, specifically nine months post-intervention). Methods: We conducted a prospective study with an experimental group of surgical nursing postgraduate students who participated in MAES© high-fidelity simulation sessions, and a control group of postgraduate nursing students who attended traditional theoretical–practical sessions at two universities in Catalonia (Spain). The levels of competence were compared between the two groups and at different time points of the study. Results: The score was higher and statistically significantly different in the experimental group for all the competencies, with a large effect size at every measurement point previously mentioned. Conclusions: The postgraduate nurses were the most competent in the clinical safety of surgical patients when they trained with the MAES© methodology than when they learned through traditional theoretical–practical workshops. The learning of surgical safety competencies was more stable and superior in the experimental group who trained with MAES©, as compared to the control group.

Managing surgical patients with a COVID-19 infection in the operating room: An experience from Indonesia

Background

The Coronavirus and the COVID-19 pandemic in 2020 have significantly impacted hospital care, including surgery practice. Hospitals must balance patient care, staff safety, resource availability, and medical ethics. Differences in community infection trends, national policies, availability of resources and technology, plus local circumstances may make uniform management impossible globally. This paper described the practical workflow of emergency COVID-19 surgery in a tertiary referral national hospital in Indonesia.

Method

This study focused on the process of preparation for COVID-19 surgery from March 2020-March 2021. We also described the available facilities in terms of equipment and human resources.

Results

Steps of COVID-19 surgery preparations were described, such as the setup of general and infectious triage in the emergency department, development of preoperative screening protocol for COVID-19, designation of a specialized COVID-19 operating room and surgical staff, changes in preoperative surgery and anesthesia workflow, development of checklists and postoperative monitoring on staff health.

Conclusions

Changes in the workflow are essential during the pandemic for safe surgery. These changes require a multidisciplinary approach, communication, and a continued willingness to adapt. We recommend local adaptation of our general workflow for emergency surgery during an epidemic or pandemic.

Rates of Serious Surgical Errors in California and Plans to Prevent Recurrence

IMPORTANCE

Despite widespread recognition and known harms, serious surgical errors, known as surgical never events, endure. The California Department of Public Health (CDPH) has developed an oversight system to capture never events and a platform for process improvement that has not yet been critically appraised.

OBJECTIVES

To examine surgical never events occurring in hospitals in California and summarize recommendations to prevent future events.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study identified 386 CDPH hospital administrative penalty reports, of which 142 were ascribable to never events occurring during surgery. These never events were identified and summarized from January 1, 2007, to December 31, 2017. A directed qualitative approach was used to analyze CDPH-mandated corrective steps to reduce future errors in this multicenter study of all accredited hospitals in California. Inclusion of surgical never event records was based on definitions established by the US Department of Health and Human Services National Quality Forum. Data analysis was performed from January 1, 2019, to November 30, 2020.

EXPOSURES

Never events include death or disability of an American Society of Anesthesiologists class I patient, wrong site or wrong surgery, retained foreign objects, burns, equipment failure leading to intraoperative injury, nonapproved experimental procedures, insufficient surgeon presence or privileges, or fall from the operating room table.

MAIN OUTCOMES AND MEASURES

Incident rates, consequences, and improvement plans to prevent additional never events were outcomes of interest.

RESULTS

A total of 142 never events were reported to the CDPH (1 per 200 000 operations). Annual surgical volume for hospitals with events was 9203 vs 3251 cases for hospitals without events (P < .001). A total of 94 of 142 events (66.2%) were retained foreign objects ranging from Kocher clamps to drain sponges. Wrong site or patient surgery accounted for 22 events (15.5%), surgical burns for 11 (7.7%), and other for 15 (10.6%). Other included insufficient surgeon presence, equipment failure, or falls in the operating room. Improvement plans included 18 unique categories of recommendations from regulators, many focusing on proper use of checklists. Regulators mandated a mean (SD) of 13 (7) corrective actions in the improvement plans. Policy adherence monitoring (119 [90.2%]), revision of existing policy (84 [63.6%]), and education regarding policy (83 [62.9%]) were common action items, whereas disciplinary action toward staff was rare (11 [8.3%]).

CONCLUSIONS AND RELEVANCE

Surgical never events are a rare issue in California. Numerous strategies have evolved to reduce errors, many involving the thorough and proper use of intraoperative checklists.

The impact of a surgical checklist on surgical outcomes in an academic institution

OBJECTIVE

To determine the influence of a surgical checklist (SC) on morbidities and compliance with safety measures.

STUDY DESIGN

Before-and-after-intervention study.

SAMPLE POPULATION

Three thousand two hundred eighty-six dogs: 1375 dogs pre-SC and 1911 post-SC.

METHODS

Completion of safety measures and occurrence of morbidity and/or mortality during hospitalization and up to death or 30-days postoperatively were recorded.

RESULTS

Safety measures were more frequently completed post-SC, including oral confirmation of patient identity (467/1177 [40%] vs. 1911/1911 [100%]) and oral confirmation of surgical site (568/1175 [48%] vs. 1911/1911 [100%]). In addition, duration of anesthesia decreased from 241 to 232 min (t = 2.824; p = .005); a greater proportion of animals that were intended to receive antibiotics did so prior to incision (1142/1316 [86.8%] vs. 1656/1845 [89.8%] [χ² = 6.70, p = .01]); and fewer dogs had unplanned return to the OR (32/1065 [3.0%], vs. 21/1472 [1.4%]) (χ² = 7.52, p = .006). No difference in surgical site infection (adjusted odds ratio 1.02 [95%CI: 0.63-1.66]); morbidity, (adjusted odds ratio 1.00 [95%CI: 0.77-1.29]); or death within 30 days (adjusted odds ratio 1.15 [95%CI: 0.72-1.83]) was detected on multivariable logistic regression analysis. The checklist prevented one wrong-site surgery.

CONCLUSION

Implementation of the checklist at our institution led to a decrease in anesthesia duration, increased administration of planned perioperative antibiotics before incision, increased completion of safety measures, and decreased unexpected return to the OR.

IMPACT

Despite the lack of effect on morbidities, the use of SC is recommended to improve compliance with safety measures and potentially prevent rare catastrophic events.

Normalization of Deviance: Concept Analysis

Normalization of deviance is a phenomenon demonstrated by the gradual reduction of safety standards to a new normal after a period of absence from negative outcomes, which suggests that the absence of negative outcomes tends to reinforce the behaviors associated with cutting corners, bypassing safety checklists, and ignoring alarms. While the concept was first identified within the National Aeronautics and Space Administration, it has a strong, dangerous presence within health care, holding specific peril within high-risk environments such as the operating room. The aims of this article are to (1) analyze the concept of normalization of deviance and (2) identify the role of normalization of deviance with respect to the behavior of nurses in high-risk health care environments to prevent adverse patient outcomes. The steps outlined by Walker and Avant are applied to guide the concept analysis.

Causes and Effects of Introducing Surgery Safety Checklist: A Review

The medical treatment process, particularly surgery, is inescapably bound to potential complications or undesirable adverse events. This narrative review aims to present the causes and effects of the introduction of the WHO Surgery Safety Checklist (SSC), the use of which is expected to reduce the number of perioperative errors, complications, and mortality. To achieve this objective, we performed a bibliometric analysis of medical citations indexed in the PubMed database using the SSC subject heading. Findings revealed a total of 1441 articles meeting inclusion status, with 1171 published during the last decade. After the screening of titles and abstracts, the members of the research team selected 75 articles, deemed most relevant for inclusion in the review, which were then thoroughly analyzed. All in all, the findings were that the use of SSC appreciably reduced the number of simple logistic errors in the perioperative period decreasing the frequency of resulting complications and mortality.

Development and validation of a technology for obstetric intraoperative care safety

OBJECTIVES

to develop and validate an obstetric surgical safety checklist for intraoperative care.

METHODS

this is a methodological study with two phases: integrative review in databases, using selection criteria and descriptors to synthesize the evidence and develop the checklist; checklist content validation, with 37 judges, who answered a Likert-type questionnaire. For analysis, a >85% content validation index was applied.

RESULTS

the checklist's first moment reached a 96.1 content validation index; the second moment, 95.5; the third moment, 98.9. Thus, the validation index of all verifying sections present in the three surgical moments was 97.1. Cronbach's Alpha value was 95.57%.

CONCLUSIONS

the checklist items were validated by judges, with improvement of some items and insertion of others.

Wrong-Site Surgery in Pennsylvania During 2015–2019: A Study of Variables Associated With 368 Events From 178 Facilities

Wrong-site surgery (WSS) is a well-known type of medical error that may cause a high degree of patient harm. In Pennsylvania, healthcare facilities are mandated to report WSS events, among other patient safety concerns, to the Pennsylvania Patient Safety Reporting System (PA-PSRS) database. In the study we identified instances of WSS events (not including near misses) that occurred during 2015–2019 and were reported to PA-PSRS. During the five-year period, we found that 178 healthcare facilities reported a total of 368 WSS events, which was an average of 1.42 WSS events per week in Pennsylvania. Also, we revealed that 76% (278 of 368) of the WSS events contributed to or resulted in temporary harm or permanent harm to the patient. Overall, the study shows that the frequency of WSS varied according to a range of variables, including error type (e.g., wrong side, wrong site, wrong procedure, wrong patient); year; facility type; hospital bed size; hospital procedure location; procedure; body region; body part; and clinician specialty. Our findings are aligned with some of the previous research on WSS; however, the current study also addresses many gaps in the literature. We encourage readers to use the visuals in the manuscript and appendices to gain new insight into the relation among the variables associated with WSS. Ultimately, the findings reported in the current study help to convey a more complete account of the variables associated with WSS, which can be used to assist staff in making informed decisions about allocating resources to mitigate risk.

Perioperative nurses' experiences in relation to surgical patient safety: A qualitative study

Surgical patient safety remains a concern worldwide as, despite World Health Organization recommendations and implementation of its Surgical Safety Checklist, adverse events continue to occur. The aim of this qualitative study was to explore the views and experiences of perioperative nurses regarding the factors that impact surgical patient safety. Data were collected through five focus groups involving a total of 50 perioperative nurses recruited from four public hospitals in Spain. Content analysis of the focus groups yielded four main themes: personal qualities of the perioperative nurse, the surgical environment, safety culture, and perioperative nursing care plans. One of the main findings concerned barriers to the exercise of leadership by nurses, especially regarding completion of the Surgical Safety Checklist. Some of the key factors that impacted the ability of perioperative nurses to fulfil their duties and ensure patient safety were the stress associated with working in the operating room, time pressures, and ineffective communication in the multidisciplinary team. Targeting these aspects through training initiatives could contribute to the professional development of perioperative nurses and reduce the incidence of adverse events by enhancing the surgical safety culture.

Structured Feedback Enhances Compliance with Operating Room Debriefs

BACKGROUND

Surgical debriefs help reduce preventable errors in the operating room (OR) leading to patient injury. However, compliance with debriefs remains poor. The objective of this study was to evaluate the role of structured feedback to surgeons in improving compliance with and quality of surgical debriefs.

MATERIALS AND METHODS

Surgical cases at an 875-bed urban teaching hospital from January-June 2019 were audited via audio/video recording to evaluate debrief performance. Debriefs were evaluated for clinical completeness and teamwork quality via two structured forms. Surgeons received an evaluation of their debrief performance at two time points during the study period (February and April). Univariate and mixed-effects regression analyses were used to assess changes in debrief compliance and quality over time.

RESULTS

A total of 878 surgical cases performed by 61 surgeons were reviewed: 198 (22.6%) cases during Period 1 (P1), 371 (42.3%) P2, and 309 (35.1%) P3. The rate at which a debrief occurred was 62.1% in P1, 73.0% in P2, and 82.2% in P3 (P < 0.001). Debriefs were 1.96 (95% CI 1.31-2.95, P = 0.001) times more likely to be completed during P2 and 3.21 (95% CI 2.07-5.04, P < 0.001) times more likely during P3 compared to P1. The percent of debriefs initiated by the lead surgeon increased from 59.8% in P1, to 80.0% in P2, to 81.5% in P3 (P < 0.001).

CONCLUSIONS

Providing structured feedback to surgeons on their debrief performance was associated with improvements in compliance and completeness with debriefing protocols, OR teamwork and communication, and leadership and accountability from the lead surgeons.

Good Catch Campaign: Improving the Perioperative Culture of Safety

Although health care workers feel pressure to reduce adverse events in the perioperative department, a lack of education, communication, and leadership can prevent hospital personnel from reporting good catches. The purpose of this evidence-based quality improvement project was to improve the culture of safety in our perioperative department by implementing the Good Catch Campaign. An interprofessional team led staff member education after implementing a standardized electronic reporting system and debriefing process to occur after good catches. Staff members reported 391 good catches from all perioperative areas during the six-month postimplementation period. Staff members completed the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture before and six months after implementation; scores improved in five areas: communication openness, feedback and communication about error, frequency of event reporting, nonpunitive response to error, and organizational learning and continuous improvement. The campaign was a successful strategy for improving perioperative patient safety.

Clinician-to-Clinician Communication of Patient Goals of Care Within a Surgical Intensive Care Unit

BACKGROUND

Little is known about the process by which inpatient teams document and convey goals of care (GOC) for critically ill surgical patients. We sought to explore clinician perspectives on the barriers and facilitators to clinician-to-clinician communication and delivery of goal-concordant patient care.

METHODS

Purposive and snowball sampling were used to recruit a multidisciplinary sample of clinicians who held roles in a surgical intensive care unit at a single tertiary care facility. Semistructured interviews with clinicians were conducted between September and December 2017 to assess clinician experiences with communicating and honoring patient GOC. Two independent coders performed qualitative coding in an iterative fashion using a framework approach. Inter-rater agreement was measured by kappa coefficient.

RESULTS

Thirty-three clinicians from multiple disciplines including surgery, anesthesiology, nursing, and social work, were interviewed. Analysis revealed that clinicians in all disciplines felt responsible for honoring patient GOC. Conflicts over patient GOC and how to honor them arose between clinicians with longitudinal patient relationships (preoperative and postoperative) and those with single-phase relationships (postoperative). Barriers to clinician-to-clinician communication and delivery of goal-concordant care included inaccessible records, lack of protocols, and difficulty in documenting complex conversations. Facilitators included recognition of a patient's unique treatment priorities and family members with a unified understanding of a patient's GOC.

CONCLUSIONS

Differences in the clinician-patient relationships and difficulty accessing information about patient preferences contribute to clinician conflicts and concerns with the goal concordance of patient care.

Looking beyond the checklist: An ethnography of interprofessional operating room safety cultures

The Surgical Safety Checklist (SSC) has been adopted in operating rooms (OR) worldwide to reduce medical errors, increase patient safety and improve interprofessional communication. Despite often high compliance rates, recent studies suggested the SSC has not been associated with significant reductions in operative mortality or complications. This ethnographic study sought to understand this disconnection through approximately 50 hours of observation in the OR and 10 in-depth semi-structured interviews with surgeons, nurses, and anaesthesiologists in orthopaedic surgery. Inductive thematic analysis was used to analyse the data. By spending time in the OR and listening to the staff, this study was able to look beyond what "ought" to be happening in the OR and garner a deep understanding of the realities of OR work that acknowledges the complexities of surgical culture in which the SSC is being implemented. This study found SSC compliance was influenced by the perceived (un)importance of individual checklist items within the orthopaedic setting. Additionally, there remains a need to further explore patients' involvement in their operative experience.

Is video observation as effective as live observation in improving teamwork in the operating room?

BACKGROUND

Teamwork in the operating room decreases the risk of preventable patient harm. Observation in the operating room allows for evaluation of compliance with best-practice surgical guidelines. This study examines the relative ability of video and live observation to promote operating room teamwork.

METHODS

Video and audio cameras were installed in 2014 into all operating rooms at an 875-bed, urban teaching hospital. Recordings were chosen at random for review by an internal quality improvement team. Concurrently, live observers were deployed into a random selection of operations. A customized tool was used to evaluate compliance to TeamSTEPPS skills during surgical briefs and debriefs.

RESULTS

A total of 1,410 briefs were evaluated: 325 (23%) through live observation and 1,085 (77%) through video; 1,398 debriefs were evaluated: 166 (12%) live and 1,232 (88%) video. For briefs, greater compliance was observed under live observation compared to video for recognition of team membership (87% vs 44%, P<.001), anticipation of complex procedural events (61% vs 45%, P<.001), and monitoring of resources (58% vs 42%, P<.001). For debriefs, greater compliance was observed under live observation for determination of team structure (90% vs 60%, P<.001), establishment of a leader (70% vs 51%, P<.001), postoperative planning (77% vs 48%, P<.001), case review and feedback (49% vs 33%, P<.001), team engagement (64% vs 41%, P<.001), and check back (61% vs 46%, P<.001) compared to video.

CONCLUSION

Video observations may not be as effective as evaluating live performance in promoting teamwork in the OR. Live observation enables immediate feedback, which may improve behavior and decrease barriers to compliance with surgical safety practices.

Factors affecting the complexity of dental implant restoration - what is the current evidence and guidance?

Objectives The aim of this paper is to identify the factors that affect the complexity of implant restoration and to explore the indices that help us to assess it. With this knowledge the growing number of clinicians restoring dental implants will have a better understanding of the available guidance and evidence base, and the differing levels of competence required.Study design A literature review was conducted. The selection of publications reporting on complexity was based on predetermined criteria and was agreed upon by the authors. After title and abstract screening 17 articles were reviewed. The articles that were utilised to form the ITI SAC tool and Cologne Risk Assessment we also included.Assessing complexity Two key guides are available: International Team for Implantology's Straight-forward Advanced Complex tool and the Cologne ABC risk score. While these guides help identify treatment complexity they do not provide a strong enough evidence base from which to solely base clinical decisions. The key patient factors are expectation, communication, the oral environment, aesthetic outcome, occlusion, soft tissue profile and the intra-arch distance, whereas the key technical factors are impression taking, type of retention, loading protocol and the need for provisional restorations. Human factors also have a significant effect on complexity, specifically, the experience and training of the clinician, team communication and the work environment.Conclusions There are many interconnecting factors that affect the complexity of dental implant restoration. Furthermore the two widely used indices for the assessment of complexity have been investigated, and although these offer a good guideline as to the level of complexity, there is a lack evidence to support their use. The development of evidence-based treatment and protocols is necessary to develop the current indices further, and these need to be expanded to include other critical areas, such as human factors. A practical guide to aid practitioners in reducing complexity has been proposed.

Gating the holes in the Swiss cheese (part I): Expanding professor Reason's model for patient safety

INTRODUCTION

Although patient safety has improved steadily, harm remains a substantial global challenge. Additionally, safety needs to be ensured not only in hospitals but also across the continuum of care. Better understanding of the complex cognitive factors influencing health care-related decisions and organizational cultures could lead to more rational approaches, and thereby to further improvement.

HYPOTHESIS

A model integrating the concepts underlying Reason's Swiss cheese theory and the cognitive-affective biases plus cascade could advance the understanding of cognitive-affective processes that underlie decisions and organizational cultures across the continuum of care.

METHODS

Thematic analysis, qualitative information from several sources being used to support argumentation.

DISCUSSION

Complex covert cognitive phenomena underlie decisions influencing health care. In the integrated model, the Swiss cheese slices represent dynamic cognitive-affective (mental) gates: Reason's successive layers of defence. Like firewalls and antivirus programs, cognitive-affective gates normally allow the passage of rational decisions but block or counter unsounds ones. Gates can be breached (ie, holes created) at one or more levels of organizations, teams, and individuals, by (1) any element of cognitive-affective biases plus (conflicts of interest and cognitive biases being the best studied) and (2) other potential error-provoking factors. Conversely, flawed decisions can be blocked and consequences minimized; for example, by addressing cognitive biases plus and error-provoking factors, and being constantly mindful. Informed shared decision making is a neglected but critical layer of defence (cognitive-affective gate). The integrated model can be custom tailored to specific situations, and the underlying principles applied to all methods for improving safety. The model may also provide a framework for developing and evaluating strategies to optimize organizational cultures and decisions.

LIMITATIONS

The concept is abstract, the model is virtual, and the best supportive evidence is qualitative and indirect.

CONCLUSIONS

The proposed model may help enhance rational decision making across the continuum of care, thereby improving patient safety globally.

Use of the World Health Organization Surgical Safety Checklist by Nigerian anesthetists

Background

Surgery and anesthesia are essential parts of global healthcare. Surgical intervention has been largely beneficial but remains associated with significant morbidity and mortality. The increasing complexity of surgical interventions has made providers more prone to avoidable errors. The World Health Organization Surgical Safety Checklist (WHO SSC) was disseminated worldwide with the aim of reducing perioperative morbidity and mortality.

Objective

There is a paucity of data to assess awareness and use of WHO SSC in low- and middle-income countries. The aim of this study is to evaluate the knowledge and use of WHO SSC by Nigerian anesthetists.

Methodology

A structured self-reporting questionnaire was distributed to Nigerian physician anesthetists. One hundred and twenty-two questionnaires were distributed with 102 completed reflecting a response rate of 83.6%.

Results

Awareness of the WHO SSC was reported by 93.1% of the respondents. Routine use of the checklist was reported by 62.7% of the respondents mostly in the teaching hospitals compared with the general hospitals and comprehensive health centers (86.2%, 23.3% and 14.3%, P = 0.0001). The respondents who had a perception that WHO SSC does not prevent errors were the least likely to use it (odds ratio: 0.08, P = 0.0117).

Conclusion

This study identified a high level of awareness and use of the WHO SSC by physician anesthetists in Nigeria. However, its use is mostly use of The WHO SSC list by Nigerian anesthetists in teaching hospitals.

Should nurses be allowed to perform the pre-operative surgical site marking instead of surgeons? A prospective feasibility study at a Swiss primary care teaching hospital

Background

Surgical site marking is one important cornerstone for the principles of safe surgery suggested by the WHO. Generally it is recommended that the attending surgeon performs the surgical site marking. Particularly in the case of same day surgery, this recommendation is almost not feasible. Therefore we systematically monitored, whether surgical site marking can be performed by trained nursing staff.

The aim of the study was to find out whether surgical site marking can be carried out reliably and correctly by nurses.

Methods

The prospective non-controlled interventional study took place in a single primary care hospital of Uster in Switzerland. During a pilot phase of 3 months (starting October 2012) the nursing staff of a single ward was trained and applied the surgical site marking on behalf of the responsible surgeon. After this initial phase the new concept was introduced in the entire surgical department. 12 months after the introduction of the new concept an interim evaluation was performed asking whether the new process facilitates daily routine and surgical site marking was performed correctly. 22 months after the introduction a prospective data collection monitored for one month whether the nursing staff carried out surgical site marking independently and correctly. Data were collected by a patient-accompanying checklist that was completed by the nursing staff, the staff in the operating room and the responsible surgeons.

Results

The stepwise implementation of the new concept of surgical site marking was well accepted by the entire staff. 150 patient-accompanying checklists were analyzed. 22 data sheets were excluded from the analysis. 90% (n = 115/128) of the surgical site markings were correctly performed. For the remaining 10% either a surgical site marking was not necessary or the nursing staff asked a surgeon to mark the correct surgical site. During the whole study time of almost 3 years, no wrong-site surgery occurred.

Conclusion

Surgical site marking can be performed by trained nurses. However, the attending surgeon remains fully responsible of the correct operation on the correct patient.

Gossypibomas in India - A systematic literature review

Purpose of Review:

Gossypibomas remain a dreaded and unwanted complication of surgical practice. Despite significant interest and numerous guidelines, the number of reported cases remains sparse due to various factors, including potential legal implications. Herein, we review related data from India to ascertain if the problem is better or worse than that reported in world literature.

Materials and Methods:

A literature search was performed on PubMed and Google Scholar, to collect and analyze all case reports and case reviews regarding the condition in India.

Results:

On analysis of the results, there were 100 publications reporting a total of 126 events. The average patient age was 38.65 years. Average time to discovery was 1225.62 days. Forty-nine percent of reported cases were discovered within the 1^st year. The most common clinical features were pain (73.8%), palpable mass (47.6%), vomiting (35%), abdominal distention (26%), and fever (12.6%). Spontaneous expulsion of the gossypiboma was noted in five cases (3.96%). Transmural migration was seen in 36 cases (28.57%).

Conclusions:

Despite advancements in surgical approaches and preventive measures, gossypibomas continue to be a cause of significant morbidity. A safe working culture, open communication, teamwork, and an accurate sponge count remain our best defence against this often unpredictable complication of surgery.

Impact of the Standardized Surgical Checklist on Communication and Teamwork Among Interdisciplinary Surgical Team Members

Traditional timeouts done ineffectively before surgical procedures can result in late blood product requests, inadequate preparation of needed intraoperative apparatus, improper administration of required antibiotics, and operating room (OR) time delays. This clinical concern is important to address because based on current evidence, implementing a Standardized Surgical Checklist (SSC) during timeout can impact patient safety by reducing complications following surgery and can promote good communication and teamwork among the care team. This quality improvement project is aimed to develop, implement, and evaluate the impact of SSC on communication and teamwork among an interdisciplinary surgical care team at Los Angeles County and University of Southern California Medical Center (LAC + USC). The design of this project was a pre- and postinnovation survey. The participants were the members of the interdisciplinary care team who participated in the surgical timeout before and after the innovation was implemented. The surveys consisted of 219 participants. Results from an independent t test demonstrated that the mean improvement score for both communication (t = −3.704, df = 190, p < .001) and teamwork (t = −3.028, df = 184, p = .003) were significantly higher in the postinnovation group than in the preinnovation group. These results indicate that SSC can improve communication and teamwork among providers inside the OR which can potentially lead to a safer delivery of care.

Effectiveness of Surgical Safety Checklists in Improving Patient Safety

Wrong-site surgery is all too common. Despite more than a decade of campaigns by major organizations to prevent these events, there are still reports of such mistakes. This article reviews the recent literature on surgical safety checklists and other tools designed to prevent wrong-site surgery and improve patient safety in the operating room. Emphasis is placed on how well institutions comply with these guidelines, the perceptions and attitudes of those who are asked to implement them, and their effectiveness. The literature shows that the implementation of such protocols has improved patient safety. In general, these efforts are viewed favorably by operating room personnel. However, the role of these checklists and other tools in reducing wrong-sided surgeries has not been proven. The goal of the health care profession should be to continue to improve on the advances that have been made in implementing surgical checklists and preventing wrong-site surgery. Practitioners at the authors' institution are continuously searching for ways to improve on the current protocols to prevent wrong-site surgeries. The authors recently employed a protocol in which surgical instruments are kept in the back of the room, away from the patient, until completion of the surgical time-out. This practice helps to ensure that team members are not distracted or preoccupied with setting up equipment during the time-out. This approach also helps to mitigate the hierarchal style in the operating room.

Interprofessional simulation training for perioperative management team development and patient safety

Establishment of a perioperative management team construct including anaesthesiologists, surgeons, nurses, and other medical staff is essential to optimize safe surgical care. Simulation based education and training provides a unique and effective approach to development of competency and application of relevant technical and non-technical perioperative professional skills such as meta-cognitive ability, caution, shared decision-making, leadership and communication. Development of high functioning perioperative teams can be accomplished through simulation based training.

[Wrong site surgery : Incidence, risk factors and prevention]

BACKGROUND

Wrong site surgery defines a category of rare but totally preventable complications in surgery and other invasive disciplines. Such complications could be associated with severe morbidity or even death. As such complications are entirely preventable, wrong site surgery has been declared by the World Health Organization to be a "never event".

MATERIAL AND METHODS

A selective search of the PubMed database using the MeSH terms "wrong site surgery", "wrong site procedure", "wrong side surgery" and "wrong side procedure" was performed.

RESULTS

The incidence of wrong site surgery has been estimated at 1 out of 112,994 procedures; however, the number of unreported cases is estimated to be higher. Although wrong site surgery occurs in all surgical specialities, the majority of cases have been recorded in orthopedic surgery. Breakdown in communication has been identified as the primary cause of wrong site surgery. Risk factors for wrong site surgery include time pressure, emergency procedures, multiple procedures on the same patient by different surgeons and obesity. Check lists have the potential to reduce or prevent the occurrence of wrong site surgery.

CONCLUSION

The awareness that to err is human and the individual willingness to recognize and prevent errors are the prerequisites for reducing and preventing wrong site surgery.

Assessment of Three "WHO" Patient Safety Solutions: Where Do We Stand and What Can We Do?

Background:

Most medical errors are preventable. The aim of this study was to compare the current execution of the 3 patient safety solutions with WHO suggested actions and standards.

Methods:

Data collection forms and direct observation were used to determine the status of implementation of existing protocols, resources, and tools.

Results:

In the field of patient hand-over, there was no standardized approach. In the field of the performance of correct procedure at the correct body site, there were no safety checklists, guideline, and educational content for informing the patients and their families about the procedure. In the field of hand hygiene (HH), although availability of necessary resources was acceptable, availability of promotional HH posters and reminders was substandard.

Conclusions:

There are some limitations of resources, protocols, and standard checklists in all three areas. We designed some tools that will help both wards to improve patient safety by the implementation of adapted WHO suggested actions.

Human error in daily intensive nursing care

OBJECTIVES

To identify the errors in daily intensive nursing care and analyze them according to the theory of human error.

METHOD

Quantitative, descriptive and exploratory study, undertaken at the Intensive Care Center of a hospital in the Brazilian Sentinel Hospital Network. The participants were 36 professionals from the nursing team. The data were collected through semistructured interviews, observation and lexical analysis in the software ALCESTE®.

RESULTS

Human error in nursing care can be related to the approach of the system, through active faults and latent conditions. The active faults are represented by the errors in medication administration and not raising the bedside rails. The latent conditions can be related to the communication difficulties in the multiprofessional team, lack of standards and institutional routines and absence of material resources.

CONCLUSION

The errors identified interfere in nursing care and the clients' recovery and can cause damage. Nevertheless, they are treated as common events inherent in daily practice. The need to acknowledge these events is emphasized, stimulating the safety culture at the institution.