Avoid/reduce error
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
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,
Develop
“near miss” reporting
mechanisms
“The doctor is the master
EURO EMRO
PAHO I
WPRO I
PAHO II
Manila, Philippines
Seattle, USA
WPRO II
AFRO
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
LET US ALL
SAVE LIVES
THRU SAFE
SURGERY!
“The best way to predict
the future is to create it!”
Peter