Effect of a comprehensive surgical safety system on patient outcomes

The incidence, root-causes, and outcomes of adverse events in surgical units: implication for potential prevention strategies

Background

We need to know the scale and underlying causes of surgical adverse events (AEs) in order to improve the safety of care in surgical units. However, there is little recent data. Previous record review studies that reported on surgical AEs in detail are now more than ten years old. Since then surgical technology and quality assurance have changed rapidly. The objective of this study was to provide more recent data on the incidence, consequences, preventability, causes and potential strategies to prevent AEs among hospitalized patients in surgical units.

Methods

A structured record review study of 7,926 patient records was carried out by trained nurses and medical specialist reviewers in 21 Dutch hospitals. The aim was to determine the presence of AEs during hospitalizations in 2004 and to consider how far they could be prevented. Of all AEs, the consequences, responsible medical specialty, causes and potential prevention strategies were identified. Surgical AEs were defined as AEs attributable to surgical treatment and care processes and were selected for analysis in detail.

Results

Surgical AEs occurred in 3.6% of hospital admissions and represented 65% of all AEs. Forty-one percent of the surgical AEs was considered to be preventable. The consequences of surgical AEs were more severe than for other types of AEs, resulting in more permanent disability, extra treatment, prolonged hospital stay, unplanned readmissions and extra outpatient visits. Almost 40% of the surgical AEs were infections, 23% bleeding, and 22% injury by mechanical, physical or chemical cause. Human factors were involved in the causation of 65% of surgical AEs and were considered to be preventable through quality assurance and training.

Conclusions

Surgical AEs occur more often than other types of AEs, are more often preventable and their consequences are more severe. Therefore, surgical AEs have a major impact on the burden of AEs during hospitalizations. These findings concur with the results from previous studies. However, evidence-based solutions to reduce surgical AEs are increasingly available. Interventions directed at human causes are recommended to improve the safety of surgical care. Examples are team training and the surgical safety checklist. In addition, specific strategies are needed to improve appropriate use of antibiotic prophylaxis and sustainable implementation of hygiene guidelines to reduce infections.

Clinical care checklists: salvations or frustrations?

The chief of surgery at a large private hospital read a paper reporting that implementation of a comprehensive surgical checklist greatly improved mortality and morbidity. The hospital has agreed to cover the cost of implementation. A special meeting of the surgical staff on implementing the checklist did not go well. The opposition to checklists ranged from residual chafing about past experience when practice guidelines went awry to acerbic assertions that the hospital's leadership has no right to tell surgeons how to practice. A dozen surgeons abruptly left, and all except a handful were piqued. Most agreed that the data may be flawed and that the hospital should therefore wait until additional data confirm the results. What should the chief of surgery do? A. Institute the checklist. Colleagues will appreciate the results later. B. Form a committee to evaluate the data. C. Wait for confirming papers to appear in the surgical literature. D. Start a pilot study with volunteer surgeons. E. Move to a new hospital where the staff is more progressive.

Can the surgical checklist reduce the risk of wrong site surgery in orthopaedics?--Can the checklist help? Supporting evidence from analysis of a national patient incident reporting system

BACKGROUND

Surgical procedures are now very common, with estimates ranging from 4% of the general population having an operation per annum in economically-developing countries; this rising to 8% in economically-developed countries. Whilst these surgical procedures typically result in considerable improvements to health outcomes, it is increasingly appreciated that surgery is a high risk industry. Tools developed in the aviation industry are beginning to be used to minimise the risk of errors in surgery. One such tool is the World Health Organization's (WHO) surgery checklist. The National Patient Safety Agency (NPSA) manages the largest database of patient safety incidents (PSIs) in the world, already having received over three million reports of episodes of care that could or did result in iatrogenic harm. The aim of this study was to estimate how many incidents of wrong site surgery in orthopaedics that have been reported to the NPSA could have been prevented by the WHO surgical checklist.

METHODS

The National Reporting and Learning Service (NRLS) database was searched between 1st January 2008- 31st December 2008 to identify all incidents classified as wrong site surgery in orthopaedics. These incidents were broken down into the different types of wrong site surgery. A Likert-scale from 1-5 was used to assess the preventability of these cases if the checklist was used.

RESULTS

133/316 (42%) incidents satisfied the inclusion criteria. A large proportion of cases, 183/316 were misclassified. Furthermore, there were fewer cases of actual harm [9% (12/133)] versus 'near-misses' [121/133 (91%)]. Subsequent analysis revealed a smaller proportion of 'near-misses' being prevented by the checklist than the proportion of incidents that resulted in actual harm; 18/121 [14.9% (95% CI 8.5-21.2%)] versus 10/12 [83.3% (95%CI 62.2-104.4%)] respectively. Summatively, the checklist could have been prevented 28/133 [21.1% (95%CI 14.1-28.0%)] patient safety incidents.

DISCUSSION

Orthopaedic surgery is a high volume specialty with major technical complexity in terms of equipment demands and staff training and familiarity. There is therefore an increased propensity for errors to occur. Wrong-site surgery still occurs in this specialty and is a potentially devastating situation for both the patient and surgeon. Despite the limitations of inclusion and reporting bias, our study highlights the need to match technical precision with patient safety. Tools such as the WHO surgical checklist can help us to achieve this.

Effective surgical safety checklist implementation

BACKGROUND

Research suggests that surgical safety checklists can reduce mortality and other postoperative complications. The real world impact of surgical safety checklists on patient outcomes, however, depends on the effectiveness of hospitals' implementation processes.

STUDY DESIGN

We studied implementation processes in 5 Washington State hospitals by conducting semistructured interviews with implementation leaders and surgeons from September to December 2009. Interviews were transcribed, analyzed, and compared with findings from previous implementation research to identify factors that distinguish effective implementation.

RESULTS

Qualitative analysis suggested that effectiveness hinges on the ability of implementation leaders to persuasively explain why and adaptively show how to use the checklist. Coordinated efforts to explain why the checklist is being implemented and extensive education regarding its use resulted in buy-in among surgical staff and thorough checklist use. When implementation leaders did not explain why or show how the checklist should be used, staff neither understood the rationale behind implementation nor were they adequately prepared to use the checklist, leading to frustration, disinterest, and eventual abandonment despite a hospital-wide mandate.

CONCLUSIONS

The impact of surgical safety checklists on patient outcomes is likely to vary with the effectiveness of each hospital's implementation process. Further research is needed to confirm these findings and reveal additional factors supportive of checklist implementation.

Wrong intraocular lens implant; learning from reported patient safety incidents

PURPOSE

To consider wrong intraocular lens (IOL) implant events in cataract surgical care reported through a national incident reporting database. To propose potential solutions for such events where possible.

METHODS

Thematic retrospective review of wrong IOL implantation incidents, as reported through clinical incident reporting methods in NHS care in England and Wales from 2003 to 2010, ascertained from database mining at the National Patient Safety Agency.

RESULTS

In total, 164 patient safety incident (PSI) reports of wrong IOL implantation were located from the study period and considered. There were 47 reports where further surgical intervention was required. All, but one of these required IOL exchange surgery. A total of 62 reports did not provide any causal reason for the wrong IOL implantation and thus provide little if any potential learning. Inaccurate biometry (n=29), wrong IOL selection (n=21), transcription errors (n=10) and handwriting misinterpretations (n=7) were causal reasons reported and are thus potential areas for ophthalmic teams to review and improve practice.

CONCLUSION

Although infrequent, biometry/IOL implant errors or wrong implants do occasionally occur during cataract care and are thus a threat to quality. There is room for improvement in incident reporting in NHS cataract care as root causation of error was usually lacking in the PSI reports. Nevertheless, lessons for improvement of care from a national incident reporting database for a frequently undertaken surgical procedure were found. Suggestions are proposed for improving quality by reducing wrong IOL problems in cataract care based on analysis of such reports.