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ARMANDO C.

CRISOSTOMO, MD, MHPEd,


FPCS, FPSCRS, FPSGS
PRESIDENT, PHILIPPINE COLLEGE OF
SURGEONS, 2008
SURGICAL ERRORS
 A woman goes to hospital for a leg operation,
and wakes up instead with a new anus.
 THIS HAPPENED IN A HOSPITAL IN BAVARIA
RECENTLY.

 A patient w/ hemothorax due to a SW Chest


presents at ER. Surgeon places chest tube on
the wrong side, no blood.
 Surgeon tells patient he needs to place a
second tube just like a milk can to let the blood
come out. He does, blood does come out.
SURGICAL ERRORS
 A patient in Chicago, got operated on the wrong
leg, and the surgeon proceeded to operate on
the right leg
 It ended up in court and the Judge dismissed
the case because the plaintiff's arguments did
not have a leg to stand on.

 The first case is true (FOX news)


 The second case is true (Philippines)
 The Chicago case is to lighten your burden
today (joke)
GOALS OF PATIENT
SAFETY
 Protect patients from harm

 Avoid/reduce error

 Promote safe operative practices


Quality & Patient
Safety
Is there really a problem?

 We were educated and trained to be good


and error-free - we CANNOT make a
mistake!

 Errors and mistakes come far & few - not


“significant”

 “It hasn’t happened to me!”


“Tyranny of Low
Numbers”
 MD’s will have small number of errors on
a personal level -> but add it up = HUGE
numbers

 “Near misses” are not counted

 Makes it difficult to get everyone on


board
Quality & Patient
Safety
 1999:
Institute of Medicine (IOM)
Report:

“To Err is Human”


Quality & Patient
Safety
1999: Institute of Medicine Report:
“To Err is Human”

The first public realization of the true


extent of patient harm and safety in the
healthcare setting
Deaths occurring from medical errors
(98,000) far outnumber deaths from
motor vehicle accidents (43,000), Breast
Cancer (42,000) and AIDS (16,000).
Quality & Patient
Safety
 Deaths from workplace injuries (6,000) are
outnumbered by deaths from medication
errors (7,000)

 There are less deaths from adverse events


occurring in nuclear reactors and the airline
industry but there are more safeguards &
monitoring processes in place

 These industries utilize checklists,


proactive reporting structure and detailed
de-briefings
Why patient safety in
surgery?
 Surgery = a public health issue

 Incidence of trauma and other surgical


conditions rising as a proportion of the
total global burden of disease

 230 million major operations performed


annually worldwide (1:25 people)
2 times more than child deliveries
Why patient safety in
surgery?
 Major complications may arise in 3-16%

 Death rate from major ORs = 0.2-10% or


7 million disabling complications and 1
million deaths each year

 Half of complications may be avoided if


certain standards of care are followed
The surgical setting is one
of the most potentially
hazardous of clinical
environments

 TraditionalOR
 Ambulatory
surgery center
 Interventional
suite
 Physician’s office
Most serious potential
complications

 Infection
 Hemorrhage
 Wrong patient/surgery/site
- 1500-2500 incidents/yr. in USA (13% of
adverse events, 76% - wrong site, 13% -
wrong patient, 11% - wrong procedure)
- most common in orthopedics (68% of
malpractice vs. ortho)
Potential Hazards in
the OR
Energy sources Chemical
 Electrical  Medications

 Thermal  Antiseptics

 Laser  Cements

 Radiological  Intravascular dyes

 Irrigating solutions
Potential Hazards . . .
Biologicals Equipment and
Devices
  Powered
Blood-borne
pathogens instruments/equip
ment
 Defibrillators
 Drug resistant
 Tourniquets
organisms
 Electrosurgical
units
 Positioning
devices
Human Factors in
Patient Safety
 Communication
patterns

 Institutional
culture

 Staffing patterns
“The breakdown in
communication . . . Most
frequently cited for
contributing to wrong site
surgery”
JCAHO
“Poor (unsafe) care is inevitable
when a complicated patient is
cared for by myriad individuals
who have not been trained to
communicate effectively as a
team.”
Dr. Gerald Healy
ACS President, 2008
Contributing Factors
to Surgical Errors
 Inadequate communication among team
members
 Incomplete review of patient health
records and diagnostic studies
 Traditional heirarchal and autocratic
structures
 Patient-related decisions made only by
physicians
 Rapid and frequent changes in technology
 Intimidating management styles
Contributing Factors .
. . Errors
 Absent or inconsistently applied rules and
procedures
 Fatigue
 Multitasking
 Time pressures/constraints
 Emergency surgery
 Cultural differences between patients,
staff members
 Staffing shortages
Contributing Factors .
. . Errors
 Blaming culture
 Confusing packaging of medications and
supplies
 Unclear instructions
 Insufficient orientation and training
 Patient characteristics requiring unusual
set-up or requirements
 Failure to include patient and family
members in assessment/decision-making
“To err is human,

to cover up is unforgivable,

and to fail to learn is


inexcusable!”
Sir Liam Donaldson
World Alliance for Patient
Safety (2004)
Error Reduction
Strategies
 Reduce reliance on memory by using
checklists, protocols, computerized
decision aids
 Improve information access of patient
records
 Support contracts for new equipment and
supplies providing staff education of use
 Standardize procedures
 Establish mechanisms to update
procedure/preference cards
Error Reduction
Strategies
 Participate in quality and process
improvement strategies
 Develop policies and procedures that
address unsafe practices
 Focus on safety aspects of products
during selection and evaluation process
 Promote safety-related clinical
competency
 Include patient & family in confirming
identification, procedure, site
Error Reduction
Strategies
 Educate
employees about potential errors
and how to avoid them

 Encourage patients and family to


participate

 Develop
“near miss” reporting
mechanisms
“The doctor is the master

of the clinical situation,

but the servant of the


patient.” Sir Liam Donaldson
World Alliance for Patient
Safety
WHO Surgical Safety
Checklist
 checklist containing basic tasks to complete
& safety checks to confirm prior to an
operation

 use of such tool will improve communication


between all members of the surgical team

 Support each separate step


technical reports outlining evidence for the
standard
its specific uses
bibliography and data supporting its inclusion,
implementation strategies, and implications (+/-)
8 Evaluation Sites

EURO EMRO
PAHO I

London, UK Amman, Jordan


Toronto, Canada

WPRO I

PAHO II
Manila, Philippines
Seattle, USA

WPRO II
AFRO

Ifakara, Tanzania SEARO


Auckland, NZ
New Delhi, India
Preliminary Pilot Site
Results
Site Cases Use of Pulse Time Out to Objective Abx @ 0- IV Access
Oximeter Confirm Airway Eval 60 mins >500 cc
Site/Pt EBL

1 377 100% 100% 96% 98% 93%


2 317 97% 8.8% 74% 52% 73%
3 232 96% 100% 9.5% 34% 7%
4 496 77% 22% 45% 25% 49%
5 338 97% 50% 72% 75% 80%
6 524 99% 99% 98% 48% 32%
7 519 100% 99% 95% 78% 67%
8 446 99% 17% 0.5% 18% 73%
Total Cases 3234
Preliminary Pilot Site
Results
Site Infection Complication Death
1 1.1% 7.2% 0.4%
2 1.3% 5.3% 0%
3 23.8% 24.2% 1.7%
4 3.4% 10.08% 3.5%
5 6.5% 14% 0%
6 9.4% 12% 2.1%
7 3.1% 6.4% 1.0%
8 4.0% 6.3% 1.3%
Total Cases 3234
WHO Checklist in PGH ORs
PGH Interim Data
PRE POST
Cases 496 500
Patient Confirmation 21.77% 64.89%
Abx at 0-60 Minutes 25.40% 55.17%
Airway Evaluation 46.17% 58.4%
2 IVs for 500cc Blood 49.23% 64%
Loss
Sponge Count 99.40% 99.8%
Complication 10.08% 7.2%
Death 3.63% 1.4%
1st Philippine Summit on
Patient Safety in Surgery
(Mar 28, 2008)
1st Philippine Summit on
Patient Safety in
Surgery (Mar 28, 2008)
Vision: A community of health professionals
collaborating to save lives thru safe
surgery
Mission: Advocating and promoting a
culture of safety in surgery thru
-policy development and implementation
- education and training
- generation and dissemination of relevant
information
- collaboration and partnership
Safe Surgery Media
Forum
PCS

ENDORSES

WHO SAFE

SURGERY

INITIATIVE
Signing of MOU between Launching of Phil.
WHO,DOH,PHIC & PCS Alliance for Patient Safety
Ongoing Efforts on
PSS
 PCS Foundation Week activities (Sept. 7-12,
2008)
- Conduct PSS summits in 11 PCS Chapters
nationwide
- Distribute checklist posters and manuals
in all ORs, DRs
 Developing research proposal on national
data base (surgical vital statistics)
 RP to host launching of WHO PSS Program
in Asia-Pacific region
Ongoing Efforts on
PSS
 Multi-sectoral task groups created
- Curriculum
- Patient safety officer
- Checklist implementation and
monitoring
- Public information and media relations
- Patient safety day celebrations
SUMMARY
 Patient safety in surgery is being recognized
as an important public health problem

 Surgeons and the whole surgical team plays


key roles in:
- protecting patients from harm
- avoiding/reducing error
- promoting safe operative practices

 PCS as lead advocate in promoting patient


safety in surgery in the Philippine setting
“The public – our present and
future patients – expect to be
cared for by a competent
surgeon who achieves quality
outcomes in a safe
environment.”
Dr. Gerald Healy
ACS President, 2008
QUALITY AND
SAFETY FOR
ALL!

LET US ALL
SAVE LIVES
THRU SAFE
SURGERY!
“The best way to predict
the future is to create it!”
Peter

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