Topic 10: and invasive procedures

Why patient safety is relevant to Although the principles described in this topic are surgery and invasive procedures 1 important for both surgical and invasive There is now plenty of evidence to show that procedures, most of the evidence in the literature patients who undergo a surgical or an invasive relates to surgical care. procedure are at increased risk of suffering an adverse event [1-3]. This is not because the Learning outcomes: knowledge and surgeons and proceduralists are careless or performance incompetent, rather it is because we now know about the many opportunities for things to go What does a student need to know wrong because of the many steps involved in (knowledge requirements): 3 surgical procedures. In addition, there are the • the main types of adverse events problems caused by surgical site infections that associated with surgical and invasive account for a significant proportion of all health procedures care; care-associated infections. This topic will assist • the verification processes for improving students to understand how patient safety surgical and invasive procedures care. principles can assist in minimizing adverse events associated with invasive procedures. There are What a student needs to do (performance many validated guidelines now available to assist requirements): 4 the health-care team deliver safe surgical care. • follow a verification process to eliminate There may not be many opportunities for students wrong patient, wrong side and wrong to implement many of these steps to improve procedure; surgical outcomes. Nonetheless they can observe • practise operating room techniques that how the health professionals communicate with reduce risks and errors (time-out, briefings, one another and what techniques they use to debriefings, stating concerns); make sure they are operating on the correct person • participate in an educational process for or doing the procedure on the correct body part. reviewing surgical and invasive procedures They can also observe what happens when health- mortality and morbidity. care professionals appear not to follow a protocol. Does this make their job harder or easier? WHAT STUDENTS NEED TO KNOW (KNOWLEDGE REQUIREMENTS) Keywords Surgical and procedural site infections, The main types of adverse events surgical/procedural errors, guidelines, associated with surgical and invasive communication failures, verification processes, procedural care 5 teamwork. The traditional way of explaining adverse events associated with surgery and invasive

Learning objective 2 procedures is usually related to the skills of the The objective of this topic is to understand surgeons and the age and physical conditions of the main causes of adverse events in surgical and the patients. Vincent and colleagues [1] believed invasive procedural care and how the use of that adverse surgical (and other procedural) guidelines and verification processes can facilitate outcomes are associated with many other factors the correct patient receiving the correct procedure such as quality of the design-interface, teamwork at the appropriate time and place. and organizational culture. Students should have

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learnt about a system approach in topic 3 as well there are more adverse events associated with as the topics on teamwork and infection control all surgery when compared to other of which is particularly relevant to this topic. departments.

A systems approach to surgical and procedural The main adverse events associated with surgical adverse events requires us to examine both latent care include: factors such as teamwork and inadequate • infections and postoperative sepsis; leadership and sharp end factors such as • cardiovascular complications; communication during handoffs and poor • respiratory complications; history taking. • thromboembolic complications. T3 T4 T9

The three main causes of adverse events in When these events have been analysed, a range surgical care are: T9 (Infection control) of pre-existing conditions (latent factors) have been identified. Some of these are: 1. Poor infection control methods • inadequate implementation of protocols or The Harvard Medical Practice Study II [2] found guidelines; that surgical-wound infections constituted the • poor leadership; second-largest category of adverse events and • poor teamwork; confirmed the long-held belief that hospital-based • conflict between the different departments staphylococcal infections constituted a great risk and the organization; for hospitalized patients, particularly those • inadequate training and preparation of receiving surgical care. The implementation of staff; safer infection control practices such as the • inadequate resources; appropriate administration of prophylactic • lack of evidenced-based practice; antibiotics has reduced postoperative infections. • poor work culture; In addition, increased attention to the risks of • overwork; transmission show health-care workers how they • lack of a system for managing as individuals and members of teams can performance. minimize the risks of cross-infection. In addition to latent factors, individuals working at the sharp end of peri-operative care are prone to Everyone has a responsibility to decrease the the following types of errors known to cause opportunities for contamination of clothing, hands adverse events, including: and equipment that have been associated with • communication failures: transmission routes. Infection control is studied in - information is provided too late to be more detail in topic 9. Students during their effective; training will be present during an operation or - information is inconsistent or inaccurate; invasive procedure. They must at all times comply - key people are excluded from the with the infection control guidelines and practise information; universal precautions. - there are unresolved issues in the team; • failure to take precautions to prevent 2. Inadequate patient management accidental injury; The operating room and environment involves • wound infections, other wound problems, intensely complex activities that may explain why technical problems and bleeding;

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• avoidable delays in treatment; patient/invasive procedures because it is • failure to take adequate history or physical recognized that one of the best ways to reduce examination; errors caused by misidentification involves • failure to employ indicated tests; implementing best-practice guidelines for • failure to act upon the results of findings ensuring the correct patient receives the correct or tests; treatment. The evidence convincingly • practising outside an area of expertise (failure demonstrates that when health-care professionals to consult, refer, seek assistance, transfer). follow endorsed guidelines and are familiar with the underlying principles supporting a uniform 3. Failure by health-care providers to approach to treating and caring for patients, communicate effectively before, during patient outcomes significantly improve. and after operative procedures. One of the biggest problems in the operating The complexity of the surgical environment is a environment is miscommunication. major factor underpinning communication errors Miscommunication has been responsible for the and they occur at all levels. A study by Lingard and wrong patients having surgery, patients having colleagues [5] described the types of operations on the wrong side or site and having communication failures that are set out in Table 17. the wrong procedure performed. Failure to communicate changes in the patient’s condition For a real example of how errors can occur in and failure to administer prophylactic antibiotics surgical procedures see have also resulted in adverse events. In addition, http://www.gapscenter.va.gov/stories/WillieDesc.asp disagreements about stopping procedures or (accessed January 2009). failing to report errors have been documented. In the Lingard study [5], 36% of communication Health professionals are often required to deal failures resulted in a visible effect such as team with many competing tasks in the operating room. tension, inefficiency, waste of resources and A surgical term is viewed by most trainees and inconvenience to patients or procedural error. students as a very busy term. In addition to high workloads, the peri-operative environment is characterized by staff with varying levels of experience and abilities. This combination of factors can seriously impact on the team’s ability to communicate accurately and timely. Communication problems occur at all stages—but particularly when patients are transferred from one phase of care to another.

The extent of adverse surgical events involving wrong site surgery [3] led The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) [4] to include wrong site surgery in its national database of “sentinel events”. Many countries now collect data about wrong

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Table 17. Types of communication failure with illustrative examples and notes

Type of Failure Definition Illustrative example and analytical note (in italics)

Occasion Problems in the situation or context The staff surgeon asks the anaesthetist whether the of the communication event antibiotics have been administered. At this point, the procedure has been under way for over an hour.

Since antibiotics are optimally given within 30 minutes of incision, the timing of this inquiry is ineffective both as a prompt and as a safety redundancy measure.

Content Insufficiency or inaccuracy apparent in As the case is set up, the anaesthesia fellow asks the staff the information being transferred surgeon if the patient has an ICU bed reserved. The staff surgeon replies that the “bed is probably not needed, and there is not likely one available anyway, so we’ll just go ahead”.

Relevant information is missing and questions are left unresolved: Has an ICU bed been requested, and what will the plan be if the patient does need critical care and an ICU bed is not available? (Note: this example was classified as both a content and a purpose failure.)

Audience Gaps in the composition of the group The nurses and the anaesthetist discuss how the patient engaged in the communication should be positioned for surgery without the participation of a surgical representative.

Surgeons have particular positioning needs so they should be participants in this discussion. Decisions made in the absence of the surgeon may lead to the need for re- positioning.

Purpose Communication events in which During a living donor liver resection, the nurses discuss purpose is unclear, not achieved or whether ice is needed in the basin they are preparing for the inappropriate liver. Neither knows. No further discussion ensues.

The purpose of this communication—to find out if ice is required—is not achieved. No plan to achieve it is articulated.

The verification processes for improving document designed to guide decision-making in a surgical care 6 specific area of . Guidelines are usually developed by a group of experts using the latest Guidelines evidence. Evidence-based practice guidelines are One of the most effective methods for improving normally endorsed at a national or international patient care is to implement an evidenced-based level by the relevant professional body and include guideline especially developed to manage a summarized statements about the latest particular condition or situation. Many terms are knowledge and preferred ways to treat. used to describe a medical guideline such as protocol, clinical guideline, clinical protocol and Good guidelines are easily disseminated and clinical practice guideline. They all mean the same designed to influence clinical practice on a broad thing. A guideline is usually an electronic or written scale.

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Good guidelines share the following identify the best way to treat patients. Often characteristics: guidelines may not be accessible to the team who • they define the most important questions is required to use them; they may not even be relating to clinical practice in a particular field; aware of them. It is not unusual for a health-care • they attempt to identify all possible decision organization to publish a guideline but then not options and the known consequences of make sure that everyone knows about it. those decisions; Sometimes there are so many guidelines to follow • they identify each decision point followed by that people turn off and do not see the relevance the respective courses of action according to or importance of them. Being aware of the the clinical judgement and experience of the importance of using appropriate guidelines is a health professionals. first step to students asking about them and then using them. The extent of variation of practice in health care has been identified as a major problem. Institute Safe care requires that all the staff know what is of Medicine [6]. Variation caused by overuse, expected of them in relation to implementing a underuse and misuse of medical care can be guideline. The guidelines need to be accessible (are addressed by evidence-based practice, which they in a written form or are they online?) and uses the best evidence available with the goal of applicable to the workplace where they are to be lessening variation and reducing risks to patients. used. (Do the guidelines acknowledge the Health professionals working in and differences in resources and the readily available do not have the time, resources or the health professionals?) For a guideline to be effective available experts to each produce their own set of the staff must know about it, trust it, be able to guidelines. Instead, clinicians are encouraged to access it easily and be able to implement it. adapt already established guidelines and then modify them to suit their local practice and For various reasons to do with resources, locality environment. and type of patients it may be that some steps in a guideline are impractical or inappropriate. In Guidelines are necessary because the complexity such cases, the team may need to change the of health care plus the level of specialization has guideline to fit the environment or circumstances. made personal opinion or professional and When this occurs everyone needs to know about organizational subjective preferences redundant the changes so they can apply them. and unsafe. There are now hundreds of validated guidelines to assist clinicians practise safe surgery If a guideline is not followed consistently by all the such as preventing wrong site, wrong procedure, team, if people routinely skip steps, the guideline wrong person surgery and prevention of surgical will not be effective in protecting patients from site infections. adverse events. It is important that everybody, including medical students, abides by the Medical students are not always told about the protocol. Commitment of the whole team is guidelines that are used in a particular area of necessary for successful implementation of medicine. Nonetheless, they should be aware that guidelines or protocols. in many areas of clinical practice, particularly that associated with the management of chronic Some physicians may question the value of a illness, there are established guidelines that guideline particularly when they think their

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autonomy is being compromised and questioned. The JCAHO Universal Protocol™ for preventing They may feel their clinical discretion is being wrong site, wrong procedure, wrong person removed with a team approach. Sharing surgery in 2003 is one example and sets out the knowledge and information with others in the process and approach for including every team is absolutely necessary for continuity of care member of the team as well as the patient. The and achieving the best outcomes for the patients. WHO recently released guidelines for surgical care advocating the use of a checklist to Guidelines in surgical care enhance safety [7]. The main protocols in surgical care are about improved communication to ensure that the right WHAT STUDENTS NEED TO DO person is having the right procedure in the right (PERFORMANCE REQUIREMENTS) place and by the right health-care team. A quick review of the processes involved in surgery show Follow a verification process to the many steps requiring active face-to-face eliminate wrong patient, wrong side conversations particularly for consent, marking and wrong procedure and or identifying the appropriate drugs and Most medical students will have an opportunity to equipment to be used. The operating team— visit operating rooms and observe how surgical surgeons, assistants, anaesthetists, scrub teams work together. They will also observe how nurses, circulating nurses (scout nurses) and the team manages the processes involved— others in the operating room—all have to know before, during and after the surgery. During a the nature of the planned procedure, so that surgical rotation students should: everyone is aware of the management plans, • locate the main protocols used in a particular expectations of the different staff and anticipated surgical unit; outcomes for the patients. For this reason, many • understand how the guideline was developed sites now schede “time out” that takes place in and whether the processes align with the operating room where the procedure will be evidenced-based practice; performed, just before the procedure is to • read and understand why the guideline is commence. necessary; • be able to identify the steps in the verification Safe surgery requires that every member of the process including selection of the right surgical team knows the main protocols used in patient, right site and right procedure; an area of practice. It would be very unusual for • identify how conflicts are resolved in no protocols to be in place. If this is the case, the team. T4 then a member of the team should request discussion about whether a protocol is required Practise operating room techniques at a team meeting. that reduce risks and errors (time-out, briefings, debriefings, stating There is universal agreement that the best concerns) 7 approach to minimizing errors caused by Topic 4 on teamwork provides a detailed misidentification of patients is the implementation analysis of how effective teams work and the of best-practice guidelines for ensuring the actions that team members can take to effectively correct patient receives the correct treatment. contribute to improved performance and safety. In There are many guidelines addressing this issue. the surgical environment there are particular

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attributes and actions known to improve surgical • asserting oneself appropriately: care teamwork. If students are not able to - students should be able to express an participate on the team, then they can observe opinion or ask for an opinion from any how the team functions. Students should actively member of the team through questions or try to become part of the team. They can statements of opinion during critical times; respectfully ask the leader of the team if they can - students should understand that assertion be a part of the team even if they do not have any does not include routine statements or specific function or role. Being included allows the questions about a patient’s heart rate, students to better see and hear how the team tone, colour and respirations (these form members communicate with one another. If part of information sharing or inquiry); possible students should practise: • stating or sharing intentions: • participating in team briefings and - students should practise sharing debriefings: information about intentions with team - students should observe and record how members and seek feedback before health-care professionals participate in the deviating from the norm—this is important processes designed to keep the patient because it alerts the rest of the team about safe—do they use checklists, briefs, planned actions that are not routine; debriefs? • teaching: - students should evaluate their own - students should be aware that teaching is contributions to the team discussions an integral part of surgical care; about the status of the patient, including - teaching can be in a variety of formats— identity, site of surgery, condition of the short or informal information exchanges as patient and plans for recovery; well as guided hands-on learning by doing; • how to appropriately share information: - students should be receptive to learning - students should verbally share information from any of the providers (for example, with all health-care members of the team nurses can teach medical students); that relates to the assessment and • managing workload: treatment of the patient; - students should appreciate that workload - students should know the main is distributed among those according to characteristics of the procedure and plans level of knowledge and skill. for managing the patient, including knowing relevant protocols and their role in Participate in an educational process implementation; for reviewing surgical mortality and • asking questions: morbidity 8 - students should actively question Most hospitals where surgery is performed members of the team in an appropriate will have a peer review system for discussing and respectful manner; cases so that lessons can be learnt and shared - students should assess when it is among the group. Many hospitals call surgical appropriate to ask questions; review meetings a “mortality and morbidity - students should participate in and take the meeting”. These are well-established forums for opportunity to ask questions during the discussing incidents and difficult cases and are period in which the team meets to go over the main peer review method for improving future the planned procedure; patient care. Such meetings usually provide a

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confidential forum for auditing surgical the incident/area have the ability to report? complications and are necessary for improving • Are juniors, including students, encouraged to practice in a surgical department. The meetings attend and participate in mortality and may be held weekly, fortnightly or monthly and morbidity meetings? These sessions provide provide a good opportunity for learning about an excellent opportunity for students to learn errors in surgery. Because patient safety is a about errors and the processes for improving relatively new discipline, many of these meetings particular treatments and procedures. are yet to adopt a systems approach (blame free) • Are all deaths involving a surgical procedure for discussions about errors. Instead, some at the site identified and discussed? remain focused on the person who made an error • Is a written summary of the discussions kept, and use a punitive approach to discussing including any recommendations made for adverse events. When meetings adopt a “person improvement or review? approach” to discussions about errors they are often closed to other members of the operating Summary 9 team, junior doctors and medical students and This topic outlines the value of guidelines in only include the surgeons. reducing errors and minimizing adverse events. But a guideline is only useful if the people using Notwithstanding some of the problems associated the guideline trust them and understand why with the past, mortality and morbidity meetings using a guideline is better for patient care. are excellent places to learn about errors and Protocols can prevent the wrong patient receiving discuss ways to prevent them in the future. the wrong treatment as well as facilitate better Medical students should find out if the hospital communication among the team. has such meetings and ask the appropriate senior surgeon if they can attend. If this is possible, HOW TO TEACH THIS TOPIC students should observe to see if the following basic patient safety principles are demonstrated: Teaching strategies/formats • Is the meeting structured so that the underlying issues and factors associated with An interactive/didactic lecture the adverse event are the focus, rather then Use the accompanying slides as a guide the individuals involved? covering the whole topic. The slides can be • Is there an emphasis on education and PowerPoint or converted to overhead slides for a understanding, rather than apportioning projector. Start the session with the case study blame to individuals? and get the students to identify some of the • Is the goal of the discussion prevention of issues presented in the story. similar things occurring again? This requires a timely discussion of the event when Panel discussions: memories are still fresh. Invite a panel of surgeons and theatre nurses to • Are these meetings considered a core give a summary of their efforts to improve patient activity for the entire surgical team, including safety and to talk about their roles and the technicians and managers as well as the responsibilities. This can help students appreciate clinicians (medical, , , the role of teamwork in surgery and invasive allied health)? procedures. Students could also have a pre- • Does everyone who had any involvement with prepared list questions about adverse event

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prevention and management and have time the later years of the programme. Nevertheless scheduled for their questions. there is no reason why students could not be exposed to them from the very first year of study. A small group discussion session • Students could attend a surgical procedure The class can be divided up into small and observe and record the activities groups and three students in each group be undertaken by the team to ensure that the asked to lead a discussion about one category of patient being operated on is the right patient, adverse events associated with surgery. Another that they are having the right procedure and student can focus on the tools and techniques at the right time. available to minimize opportunities for errors and • Students could observe a surgical team, another could look at the role of mortality and identifying who is on the team, how they morbidity meetings. functioned and how they interacted with the patient. The tutor facilitating this session should also be • Students can attend a mortality and morbidity familiar with the content so information can be meeting and write a brief report as to whether added about the local and clinical the basic patient safety principles were environment. applied during the meeting. • Students could follow a patient through the Simulation exercises peri-operative process and observe the Different scenarios could be developed activities or tasks that focused on the about adverse events in surgery and the patient’s safety. techniques for minimizing the opportunities for • Students should examine and critique the errors. These could mainly involve junior staff protocol used for the patient verification having to speak up to more senior staff to avert an process including observations of the team’s incident such as the wrong patient being operated knowledge and adherence of it. on or the wrong limb being prepared. • Students should observe how patient information is communicated from the wards Different scenarios could be developed for the to the operating rooms and back to the students: wards. • practising the techniques of briefs, debriefs and assertiveness to improve communication After these activities, students should be in theatres; asked to meet in pairs or small groups and • role play using a “person approach” and then discuss with a tutor or clinician what they a “system approach” in a mortality and observed and whether the features or morbidity meetings; techniques being observed were present or • role play a situation in theatre where a absent, and whether they were effective. medical student notices something is wrong and needs to speak up. CASE STUDIES Operating room and ward activities This topic offers many opportunities for integrated Arthroscopy performed on wrong knee activities during the time when students are This demonstrates the role of the team in ensuring assigned to a surgical ward. This will often be in the correct procedure is performed and how

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hierarchies are a barrier to safe care. was very well equipped.

Brian injured his left knee while exercising and Anaesthesia was induced at 08:35 but it was not was referred by his general practitioner to an possible to insert the laryngeal mask airway. Two orthopaedic surgeon. The orthopaedic surgeon minutes later, the patient’s oxygenation began to obtained consent to perform an examination of deteriorate and she looked cyanosed (turning the left knee under anaesthetic as a day surgery blue). Her oxygen saturation at this time was 75% procedure. Two registered nurses confirmed as (anything less than 90% is significantly low) and part of the ordinary preoperative processes that her heart rate was raised. his signature appeared on the consent form for his left knee. At 08:39, her oxygen saturation continued to deteriorate to a very low level (40%). Attempts to The surgeon talked to Brian before he entered the ventilate the lungs with 100% oxygen using a face operating theatre, but did not confirm which knee mask and oral airway proved extremely difficult. was to be operated on. Brian was taken into the The anaesthetist, who was joined by a consultant operating theatre and anaesthetized. The colleague tried unsuccessfully to achieve tracheal anaesthetic nurse saw a tourniquet draped over intubation to overcome the problems with the his right leg and applied it. The enrolled nurse airway. By 08:45, there was still no airway access checked the intended side on the operating list so and the situation had become “cannot intubate, she could set up and when she saw the cannot ventilate”, a recognized emergency in orthopaedic surgeon preparing the right leg, she anaesthetic practice for which guidelines are told him that she thought the other leg was the available. The nurses present appear to have intended operative site. The doctor was heard by recognized the severity of the situation, one both the enrolled nurse and scrub nurse to fetching a tracheotomy tray, another going to disagree and the right (incorrect) knee was arrange a bed in ICU. operated on. The doctors’ intubation attempts continued using Reference different laryngoscopes, but these were also Case studies. Professional Standards unsuccessful and the procedure was abandoned Committees, Health Care Complaints with the patient transferred to the recovery room. Commission, New South Wales, Annual Report Her oxygen saturation had remained at less than 1999–2000, p. 64. 40% for 20 minutes. Despite being subsequently transferred to ICU, she never regained A routine operation. consciousness and died 13 days later as a result The case illustrates the risks of anaesthetics. of severe brain damage.

A 37-year-old woman in good health was Reference scheduled for non-emergency sinus surgery Bromiley, M. Have you ever made a mistake? under general anaesthesia. The consultant Bulletin of the Royal College of Anaesthetists, anaesthetist had 16 years of experience; the ear, March. Just a Routine Operation. 2008. DVD nose and throat surgeon had 30 years available from the Clinical Human Factors Group experience, and three of the four nurses in theatre web site at www.chfg.org. were also very experienced. The operating room

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Wrong kidney removed despite a student’s the patient’s allergy to penicillin and the surgeon warning suggested clindamycin as an alternative This case demonstrates the relevance of using a preoperative antibiotic. The anaesthetist went into protocol to ensure correct patient correct site the sterile corridor to retrieve the antibiotics but correct procedure. returned and explained to the circulating nurse that he could not find any suitable antibiotics in the A male patient aged 69 was admitted for removal sterile corridor. The circulating nurse got on the of his chronically diseased right kidney phone to request the preoperative antibiotics. The (nephrectomy). Due to a clerical error, the anaesthetist explained that he could not order admission slip stated “left”. The operating list was them because there were no order forms (he transcribed from the admission slips. The patient looked through a file folder of forms). The was not woken from sleep to check the correct circulating nurse confirmed that the requested side on the preoperative ward round. The side antibiotics “were coming”” was not checked in from the notes or the consent form. The error was compounded in the operating The surgical incision was performed. Six minutes theatre when the patient was positioned for a left later the antibiotics were delivered to the operating nephrectomy and the consultant surgeon put the room and immediately injected into the patient. correctly labelled X-rays on the viewing box back This injection happened after the time of incision, to front. The senior registrar surgeon began to which was counter to protocol that requires remove the left kidney. antibiotics to be administered prior to the surgical incision in order to avoid surgical site infections. A medical student observing the operation Subsequently a nurse raised a patient concern suggested to the surgeon that he was removing and effected a change in operative planning. the wrong kidney but was ignored. The mistake was not discovered until two hours after the Case from the WHO Patient Safety Curriculum operation when the patient had not produced any Guide for Medical Schools working group. urine. He later died. Supplied by Lorelei Lingard, University of Toronto, Toronto, Canada. Reference British Medical Journal, 31 January 2002, p. 246; Telegraph, 13 June 2002. TOOLS AND RESOURCES

A failure to administer preoperative antibiotic Universal protocol for preventing wrong site, wrong prophylaxis in a timely manner according to procedure, wrong person surgery™: Carayon P. protocol Schultz K. Hundt AS. Righting wrong site surgery. This case illustrates the importance of preplanning [Case Reports. Journal Article. Research Support, and checking prior to a procedure and how Non-U.S. Government. Research Support, US protocols can minimize the risk of infection. Government, P.H.S.] Joint Commission. Journal on Quality & Safety, 2004, 30(7):405–10 The anaesthetist and the surgeon discussed the (http://www.jointcommission.org/NR/rdonlyres/E3 preoperative antibiotics required for the C600EB-043B-4E86-B04E- laparoscopic cholecystectomy that was about to CA4A89AD5433/0/universal_protocol.pdf, begin. The anaesthetist informed the surgeon of accessed May 2008).

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5 step correct patient, correct site, correct HOW TO ASSESS THIS TOPIC procedure: ACT Health (Australia), issued September 2005 A range of assessment methods are suitable for (http://www.health.act.gov.au/c/health?a=sendfile&ft this topic including observational reports, reflective =p&fid=1127862008&sid, accessed 29 April 2008). statements about surgical errors, essays, MCQ, Surgical events toolkit: Joint Commission SBA, case-based discussion and self- International Center for Patient Safety, 2007 assessment. Students can be encouraged to http://www.ccforpatientsafety.org/ accessed 29 develop a portfolio approach to patient safety April 2008). learning. The benefit of a portfolio approach is that Correct site surgery toolkit: Association of peri at the end of the student’s medical training they operative Registered Nurses (AORN) will have a collection of all their patient safety (http://www.aorn.org/PracticeResources/ToolKits/ activities. Students will be able to use this to CorrectSiteSurgeryToolKit/, accessed 29 April assist job applications and their future careers. 2008). Perioperative patient “hand-off’ toolkit: The assessment of knowledge about surgical care Association of Perioperative Registered Nurses and the potential harm to patients, about system (AORN) and the U.S. Department of Defense approach to improving surgical outcomes and the Patient Safety Program techniques for minimizing opportunities for (http://www.aorn.org/PracticeResources/ToolKits/ surgical errors are all assessable using any of the PatientHandOffToolKit/, accessed 29 April 2008). following methods: Ensuring correct surgery and invasive • portfolio; procedures: Veterans , US • case-based in discussion; Department of Veterans Affairs, Washington, DC • OSCE station; (http://www1.va.gov/vhapublications/ViewPublicat • written observations about the perioperative ion.asp?pub_ID=1106, accessed 29 April 2008). environment (in general) and the potential for WHO safe surgery saves lives: The Second error; Global Patient Safety Challenge. • reflective statements (in particular) about: (http://www.who.int/patientsafety/safesurgery/en/i - theatres and the role of teamwork in ndex.html). minimizing errors; - the role of hierarchy in the theatre and the Resources impact on patient safety; Calland JF et al. Systems approach to surgical - the systems in place for reporting surgical safety. Surgical Endoscopy, 2002, 16:1005–1014 errors; (http://www.springerlink.com/content/wfb947ub7 - the role of surgeons in learning from errors ut3re9n/fulltext.pdf, accessed 29 April 2008). and making improvements; Vincent C et al. Systems approaches to surgical - role of patients in the surgical process; quality and safety: from concept to measurement. - the effectiveness or otherwise of mortality Annals of Surgery, 2004, 239:475–482 and morbidity meetings. Cuschieri A. Nature of human error: Implications for surgical practice. Annals of Surgery 2006, The assessment can be either formative or 244:642–648 summative; rankings can range from unsatisfactory (http://www.pubmedcentral.nih.gov/articlerender.f to giving a mark. See the forms in Appendix 2 cgi?artid=1856596, accessed 29 April 2008).

227 HOW TO EVALUATE THIS TOPIC SLIDES FOR TOPIC 10: PATIENT Evaluation is important in reviewing how a SAFETY AND INVASIVE PROCEDURES teaching session went and how improvements can be made. See the Teacher’s Guide (Part A) for Didactic lectures are not usually the best way to a summary of important evaluation principles. teach students about patient safety. If a lecture is being considered, it is a good idea to plan for References student interaction and discussion during the lecture. Using a case study is one way to 1. Vincent C et al. Systems approaches to generate group discussion. Another way is to ask surgical quality and safety: from concept to the students questions about different aspects of measurement. Annals of Surgery, 2004, health care that will bring out the issues contained 239:475–482. in this topic such as the blame culture, nature of 2. Leape L et al. The nature of adverse events error and how errors are managed in other in hospitalized patients: results of the industries. Harvard Medical Practice Study II. New England Journal of Medicine, 1991, The slides for topic 10 are designed to assist the 323:377–384. teacher deliver the content of this topic. The slides 3. Kable AK, Gibberd RW, Spigelman AD. can be changed to fit the local environment and Adverse events in surgical patients in culture. Teachers do not have to use all of the Australia. International Journal for Quality in slides and it is best to tailor the slides to the areas Heath Care, 2002, 269–276. being covered in the teaching session. 4. Joint Commission on Accreditation of Healthcare Organizations. Guidelines for implementing the universal protocol for preventing wrong site, wrong procedure and wrong person surgery: Chicago, JCAHO, 2003. 5. Lingard L et al. Communication failures in the operating room: an observational classification of recurrent types and effects. Quality & Safety in Health Care, 2004, 13:330–334. 6 Crossing the Quality Chasm: a New Health System for the 21st Century. Washington DC: National Academy Press, 2001. 7. WHO safe surgery saves lives: The Second Global Patient Safety Challenge. (http://www.who.int/patientsafety/safesurger y/en/index.html) accessed January 2009.

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