Safer surgery

1. RECENT
ADVANCES IN
SAFER SURGERY
PRESENTED BY DR. SAGAR
MODERATED BY DR. ASHWIN

2. Introduction
 The concept of patient safety and avoiding harm
has existed for as long as medicine itself – the
Hippocratic Oath from the 5th century BC states
that doctors should “never do harm to anyone”.
 Until studies from 20th century neither the scale
nor causes of such harm were generally
recognised.

3. SAFER SURGERY
 Patient safety has been given many definitions.
patient safety can be defined as preventing avoidable
harm and hence safer surgery can be defined as “ a
reduction in avoidable harm to a surgical patient.”
*This definition is still open to interpretation in its
application since harm covers a wide spectrum from
psychological harm to death and whether such harm is
avoidable can also be difficult to determine .

4. Safety in surgery
 An article regarding safer surgery in uk , march , 2013 claimed that
3 worst nightmares a patient faces related to surgery –
 wrong site/side of surgery ,
 Surgery in a wrong patient ,
 retained instruments / swabs.
 These reports however don’t represent harm rates since they only
deal with specific serious consequences of surgery and also rely on
self reporting .
 Incidence reporting systems In which adverse incidents are
reported to a central system , are mandated in many hospitals but
they only capture a small number of incidents which actually occur .

5.  Reporting systems are designed to allow improvements in practice
and are intended as markers of patient safety rates.
 Retrospective notes analysis can also be used locally to identify
harm events , both to produce harm event rates and acts as a basis
for improvement.
 Global trigger tool has been developed , which consists of quick
screening of patient notes looking for trigger factors . For example –
low haemoglobin levels, admission in critical care , returns to
operation Theatre,etc (trigger factors)which if present indicate
increased probability of an adverse event .
 Major disadvantage of this method is that ,it mainly depends on
documentation.

6. How do patients suffer avoidable harm
?
1) Patient themselves: Patients have a variety of
presentations of disease , differing comorbidities , and
differing response to treatment.
An important approach in reducing these errors is
standardisation of procedures and establishing specific
guidelines which are acceptable all over the world.

7. 2) Complex disease management: There is a
spectrum of complexity in surgical management
according to diagnosis. The development of
laparoscopic surgery and use of robotics are best
examples of actual and potential changes in surgical
management.
*Many advances in surgical care involve a learning
curve for surgeons ,during this time patients may be at
increased risk of unintended harm.

8. 3) Health care professionals :
Errors by healthcare professionals
are one of the common causes for
patient harm.
Attempting to do more than one thing
at a time leads to errors. Distractions
in operation theatre may detoriate
mental and physical performance due
to stress ,fatigue and time pressures.

9. 4) Health care system: Health care is delivered by teams –
however it is not always clear who is in the team and what role
they play. On occasions the strong hierarchical structure
prevents teams members from intervening when a patient is
about to be harmed .
Trainee surgeons usually follow rotation during which they learn
different processes of health care which in turn may not always
overcome issues related to patient harm.
A combination of reduced length of training and reduced hours
per week might lead to inadequately trained surgeons .
Health care costs a considerable amount and efficiency and cost
reduction can impact patient safety.

10. BARRIERS TO HARM: Important
element of prevention of harm is the use
of defences or barriers .
Barriers can be of various forms for
example- defences or barriers for
surgeons may be “STOP” or” TIMEOUT “
moment in operation theatre , red wrist
bands for patients with history of drug
allergies etc.

11. Surgery made safer
Right surgeon ; right place and right time.
The right surgeon requires adequate training and
experience .Further, trained surgeons require updating in
current techniques .
Right time of surgery is applicable to emergency surgery.
Patient has to be operated as soon as clinically
appropriate , this has often been difficult to achieve and
has always been a high priority for healthcare
organisation.

12. Indicators of patient Safety
 Adverse event: An incident that results in harm to the patient.
 A near miss: An incident that could have resulted in unwanted
consequences but did not , either by chance or through a timely
intervention preventing the event from reaching the patient .
 A no harm event: an incident that occurs and reaches the patient
but results in no injury to the patient. Harm is avoided by chance
or due to mitigating circumstances.

13. Goals of safer surgery can be achieved by:
A. Standardisation ;
B. communication and
C. learning from incidents.

14. A. Standardisation :
 Standardisation of health care can be produced nationally
or locally, but national guidance with appropriate local
adaptation has proved to be helpful.
 Standardisation should be based on research evidence or
best practice .
 standardisation is particularly useful where healthcare is
delivered by different professionals in ever changing teams.

15.  Various examples of standardisation effecting surgical patients
are:
1) Preoperative Investigations.
2) Preoperative care if diabetes patients .
3) Preventing thromboembolism perioperatively.
4) Surgical site infection prevention.
5) Preoperative starvation time.
6) Early or clinically appropriate time of operation in critically ill
patients.
7) five steps of patient safety –Incorporating the WHO surgical
checklist.

16. B. Communication:
 Poor communication between patients and health care
professionals contributes to majority of patient adverse
incidents.
 Fair communication is needed in hand over , briefing , ward
rounds and in discussions about individual patients .
 Such communications needs to be structured , understood and
documented.
 The form of communication should be considered (face to face
or over telephone ).
 Training in and implementation of adequate communication
methods is not universal yet.

17. C. Learning from incidents:
 Incidents in which patients have or potentially could have
been harmed should be reported locally and a system in place
whereby these are analysed and appropriate action decided
and implemented , in order to reduce the risk of the same
event happening again.
 Improvement in patient safety as a result of previous incidents
is important since , because of the complexity of healthcare
and human nature, its not possible to anticipate in advance
patient harm.

18.  Unfortunately, learning from incidents is not as effective as it could be
for many reasons-
1)many incidents are not reported ,
2)the number reported is so great that it can be difficult to prioritise
appropriately ,
3)analysis is not always correct and there can be difficulty in
implementing action.
 All doctors should be trained in analysis of incidents since this will
improve their ability to learn individually from incident.
 Complaints from patient are another potential source of patient safety
incidents to be analysed and actioned as appropriate .
 Consideration should be given to the most appropriate way to
introduce patient Safety initiative.

19. Implementation of safer surgery
initiatives
 Implementing changes in healthcare can be difficult- the
system is complex and has many people involved in each
pathway, getting agreement can be difficult and time
consuming.
 The model for improvement method for implementing change
has been particularly associated with patient safety work –it
was the recommended method for implementation of the
WHO Checklist .

20.  This model suggests introducing small tests of change – a
small, change in a limited area and time and observing this
change .
 If successful it can be tried in a larger group or different areas-
with constant feedback.
 This is referred to as repeated plan do study act (PDSA)
cycle.
 The method requires a structured approach to change but is
less time consuming and requires less initial buy in from
everyone .

22. Five steps of safer surgery (by who checklist) :
1. Briefing
2. Sign in
3. Time out
4. Sign out
5. Debriefing

23. 1)Briefing:
 It Is carried out at the start of the operation before the patient is
anaesthetised.
Role of briefing:
A. To ‘walk through’ the list and anticipate any problems that might
occur, such as equipment, test results, patients not ready, ICU bed
availability etc and resolve them so that the operation runs more
efficiently – to develop contingency plans.
B. 2. To come together as a team for that list.
C. 3. To open communication between different team members to
ensure everyone is on ‘the same page’.
D. 4. To flatten hierarchy & allow anyone with concerns to speak out.

24. 2) Sign in : (before induction of Anaesthesia)
This includes
A) Confirming : identity of patient , site of surgery ,procedure,
consent.
B) Marking the site of surgery.
C) Completion of anaesthesia safety Checklist.
D) Checking equipment functional status.
E) Allergic history of patient.
F) Difficult airway/ risk of aspiration.
G) Blood loss anticipation.

25. 3)Time out: (before skin incision)
It includes:
A)Introduction of all members(names of operating surgeon,
anaesthetist, scrub nurse, technician)
B)Surgeon, anaesthetist and nurse verbally confirm patient ,
site of surgery and procedure.
C)Anticipated critical events:
I. Surgeon reviews: critical steps of the procedure, duration,
and anticipated blood loss
II. Anaesthesia team reviews: Any patient specific concerns.
III. Nursing team reviews: Confirm count and sterility of
instruments, functioning of equipment, etc.

26. D) Preoperative antibiotic (60min
prior to incision)
E) Essential imaging being displayed
( xray films, ct/mri scan films etc)

27. 4)Sign out: (before patient leaves
operating room)
Nurse verbally confirms:
a. Name of procedure recorded
b. Counts- instruments, sponge,
needles
c. Labelling of specimen if any.
d. Any equipment problems to be
addressed
e. Key concerns for recovery and
management post operatively.

28.  Debriefing: Carried out at the end of the operation.
Aim:
a) To learn what went well and what went wrong, so that
problems can be addressed and avoided in future
procedures.
b) To thank team members for what went well.

29. References
 RECENT ADVANCES IN SURGERY BY
IRVING TAYLOR – 36th edition.
 PATIENT SAFETY CURRICULUM
GUIDE – MULTI-PROFESSIONAL
EDITION – WHO 2011.
 Ten years of surgical safety checklist – a
study by DR.T.GWEISER AND DR.A.B
HAYNES , BRITISH JOURNAL OF
SURGERY, MAY,2018.
 Safer surgery – analysing behaviour in
operating theatre by Flin and Mitchel.