Effect of a comprehensive surgical safety system on patient outcomes

Standard perioperative management in gastrointestinal surgery

Introduction

The outcome of patients who are scheduled for gastrointestinal surgery is influenced by various factors, the most important being the age and comorbidities of the patient, the complexity of the surgical procedure and the management of postoperative recovery. To improve patient outcome, close cooperation between surgeons and anaesthesiologists (joint risk assessment) is critical. This cooperation has become increasingly important because more and more patients are being referred to surgery at an advanced age and with multiple comorbidities and because surgical procedures and multimodal treatment modalities are becoming more and more complex.

Objective

The aim of this review is to provide clinicians with practical recommendations for day-to-day decision-making from a joint surgical and anaesthesiological point of view. The discussion centres on gastrointestinal surgery specifically.

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.