Lecture on Patient Safety

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Surgical Public Health:

The World Health Organization and the

Safe Surgery Saves Lives Campaign

NAME, TITLE NAME, TITLE OCCASION OCCASION DATE DATE

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3 Central Problems in

Surgical Safety

1.

1. Un

Unre

re

co

cogn

gniz

ized

ed

as

a p

a pub

ub

li

lic h

c hea

ealt

lth i

h iss

ssue

ue

3.

3. La

Lack

ck

of

da

data

ta

on

surg

su

rg

er

ery a

y a

nd

ou

tc

tcom

omes

es

5.

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Problem 1: Unrecognized as public

health issue

0 0 50,000,000 50,000,000 100,000,000 100,000,000 150,000,000 150,000,000 200,000,000 200,000,000 250,000,000 250,000,000 Incident HIV Incident HIV Cases Cases Prevalent Prevalent HIV Cases HIV Cases Chi

Childbldbirtirths hs OpOpereratiationsons

234 million operations are done globally each y

234 million operations are done globally each year ear

Source: Weiser, Lancet 2008. Source: Weiser, Lancet 2008.

(5)

Problem 1: Unrecognized as public

health issue (cont.)

•

• _{Burden of surgical disease is increasing}

_{Burden of surgical disease is increasing}

worldwide

–

– Cardiovascular diseaseCardiovascular disease –

– Traumatic injuriesTraumatic injuries –

– _Cancer_Cancer –

(6)

Problem 1: Unrecognized as public

health issue (cont.)

•

• Known surgicalKnown surgical complicat

complications ions of of 3-16%

3-16% •

• _{Known death}_{Known death} rates of

rates of 0.4-0.8%0.4-0.8%

At least 7 million At least 7 million

disabling

disabling complicatcomplicationsions – including 1 million – including 1 million deaths – worldwide deaths – worldwide each year each year

=

(7)

Problem 2: Lack of Data on

Surgery and Outcomes

•

• _{Improvements in maternal mortality}

_{Improvements in maternal mortality}

depended on

depended on routine surveillance

routine surveillance

•

(8)

Problem 3: Failure to use existing

safety know-how

•

• High rates of preventable surgical site

High rates of preventable surgical site

infection result from inconsistent timing of

antibiotic prophylaxis

•

• _{Anesthetic complications are 100-1000x}

_{Anesthetic complications are 100-1000x}

higher in countries that do not

higher in countries that do not adhere to

adhere to

monitoring standards

•

• _Wrong-patie

_Wrong-patie

_nt,

_{nt, wrong-site operations}

_{wrong-site operations}

persist despite high publicity of such

events

(9)

The Safe Surgery Saves Lives

Strategy

1.

1. Pr

Prom

omot

ot

io

ion o

n of su

f su

rg

rgic

ical

al

sa

safe

fety

ty

as a

pu

publ

blic

ic

health issue

3.

3. Cr

Crea

ea

ti

tion

on

of

a chec

a ch

eckl

klis

ist t

t to i

o imp

mpr

rov

ove t

e the

he

standards of surgical safety

5.

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WHO’s 10 Objectives for Safe

Surgery

1.

1. ThThe te teaeam wm wilill opl opereratate on e on ththe ce cororrerect ct papatitienent at att the correct site.

the correct site. 2.

2. ThThe te teaeam wm wilill ul use se memeththodods ks knonown wn to to prprevevenentt harm from administration of

harm from administration of anaesthetics, whileanaesthetics, while protecting the patient from pain.

protecting the patient from pain. 3.

3. ThThe te teaeam m wiwill ll recrecogogninize ze anand ed effffecectitivevely ly prprepepararee for life-threatening loss of airway or respiratory for life-threatening loss of airway or respiratory function.

function. 4.

4. ThThe te teaeam m wiwill ll recrecogogninize ze anand ed effffecectitivevely ly prprepepararee for risk of high blood loss.

for risk of high blood loss. 5.

5. ThThe te teaeam wm wilill al avovoid id ininduducicing ng an an alallelergrgic ic or or adverse drug reaction for which the patient is adverse drug reaction for which the patient is known to be at significant risk.

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WHO’s 10 Objectives for Safe

Surgery (cont.)

1.

1. ThThe te teaeam wm wilill cl cononsisiststenentltly uy use mse metethohods ds knknowownn to minimize the risk for s

to minimize the risk for surgical site infection.urgical site infection. 2.

2. ThThe tee team am wiwill pll prerevevent int inanadvdverertetent nt reretetenntition oon of f instruments or sponges in surgical wounds.

instruments or sponges in surgical wounds. 3.

3. ThThe te teaeam m wiwill ll sesecucure re and aand accccurauratetely ly ididenentitify fy alalll surgical specimens.

surgical specimens. 4.

4. ThThe te teaeam wm wilill el effffecectitivevely ly cocommmumuninicacate te anandd exchange critical information for the safe exchange critical information for the safe conduct of the operation.

conduct of the operation. 5.

5. HoHospspititalals as and nd pupublblic ic hehealalth th sysyststemems ws wililll establish routine surveillance of surgical establish routine surveillance of surgical capacit

(12)

Currently, hospitals do MOST of the

right things, on MOST patients,

MOST of the time.

The Checklist helps us do ALL the

right things, on ALL patients, ALL the

time

Reality Check

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Advantages of Using a Checklist

•

• _Customizable_Customizable _{to local setting and needs}_{to local setting and needs} •

• SupportedSupported by evidenceby evidence •

• EvaluatedEvaluated in diverse settings around the worldin diverse settings around the world •

• PromotesPromotes adherence to established safetyadherence to established safety practices

practices •

• _{Minimal resources}_{Minimal resources} _{required to implement a far-}_{required to implement a} far-reaching safety intervention

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What is this tool that addresses the 10

objectives?

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London, UK London, UK E EUURROO EEMMRROO WPRO I WPRO I SEARO SEARO AFRO AFRO PAHO I PAHO I Amman, Jordan Amman, Jordan Toronto, Canada Toronto, Canada

New Delhi, India

Manila, Philippines Manila, Philippines Ifakara, Tanzania Ifakara, Tanzania WPRO II WPRO II Auckland, NZ Auckland, NZ PAHO II PAHO II Seattle, USA Seattle, USA

The Checklist was piloted in 8 cities

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Results

•

• Increased rate of adherence to basic

Increased rate of adherence to basic

standards from 36% to 68% – in

standards from 36% to 68% – in some

some

hospitals to almost 100%.

•

• _{Resulted in substantial reductions in}

_{Resulted in substantial reductions in}

mortality and morbidity

Source:

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What problems does this checklist

address?

•

• _{Correct patient,}

_{Correct patient,}

operation and operative

site

–

– There are between 1500 andThere are between 1500 and

2500 wrong site surgery

incidents every year in the

US.

US.¹¹

–

– In a survey of 1050 handIn a survey of 1050 hand

surgeons, 21% reported

having performed wrong-site

surgery at least once in their

career.

career.²²

¹

¹ Seiden, Archives of Surgery, 2006.Seiden, Archives of Surgery, 2006.

²

² Joint Commission, Sentinel Event Statistics, 2006.Joint Commission, Sentinel Event Statistics, 2006.

Sign In: Sign In: Time Out: Time Out: Sign Out: Sign Out:

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What problems does this checklist

address? (cont.)

•

• _{Safe Anaesthesia}

_{Safe Anaesthesia}

and Resuscitation

–

– An analysis of 1256An analysis of 1256

incidents involving general

anaesthesia in Australia

showed that pulse oximetry

on its own would have

detected 82% of them.

detected 82% of them.¹¹

¹

¹ Webb, Anaesthesia and Intensive Care, 1993.Webb, Anaesthesia and Intensive Care, 1993.

Sign In:

Time Out:

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What problems does this checklist

address? (cont.)

•

• Minimizing risk of

Minimizing risk of

infection

–

– Giving antibiotics within oneGiving antibiotics within one

hour before incision can cut

the risk of surgical site

infection by 50%

infection by 50%¹¹,, _²_²

–

– In the eight evaluation sites,In the eight evaluation sites,

failure to give antibiotics on

time occurred in almost one

half of surgical patients who

would otherwise benefit

from timely administration

¹

¹ Bratzler, The American Journal of Surgery, 2005.Bratzler, The American Journal of Surgery, 2005.

²

² Classen, New England Journal of Medicine, 1992.Classen, New England Journal of Medicine, 1992.

Time Out:

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What problems does this checklist

address? (cont.)

•

• _{Effective Teamwork}

_{Effective Teamwork}

–

– Communication is a root causeCommunication is a root cause

of nearly 70% of the

of nearly 70% of the eventsevents

reported to the Joint

Commission from 1995-2005.¹

–

– A preoperative team briefingA preoperative team briefing

was associated with enhanced

prophylactic antibiotic choice

and timing, and appropriate

maintenance of intraoperative

temperature and glycemia.

temperature and glycemia.²²,, _³_³

¹

¹ Joint Commission, Sentinel Event Statistics, 2006.Joint Commission, Sentinel Event Statistics, 2006.

²

² Makary, Joint Commission Journal on Quality and Patient Safety, 2006.Makary, Joint Commission Journal on Quality and Patient Safety, 2006.

³

³ Altpeter, Journal of the American College of Altpeter, Journal of the American College of Surgeons, 2007.Surgeons, 2007.

Time Out:

Sign Out:

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Data Collection at a National Level

(Surgical Vital Statistics)

•

• Number of surgical procedures performed in theNumber of surgical procedures performed in the operating theatre per 100,000 population per

operating theatre per 100,000 population per year

year •

• Number of Operating Theatres per 100,000Number of Operating Theatres per 100,000 population

population •

• Number of surgeons per Number of surgeons per 100,000 population100,000 population •

• Number of anesthesia professionals per 100,000Number of anesthesia professionals per 100,000 population

population •

• Day-of-surgery mortality rateDay-of-surgery mortality rate •

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Goals of the Safe Surgery Saves Lives

Program

•

• Enroll 250 hospitals in the program by

Enroll 250 hospitals in the program by

January 1st, 2009 and 2,500 hospitals by

2010.

•

• _{Enroll hospitals in countries representing}

_{Enroll hospitals in countries representing}

one fourth of the

one fourth of the world’s population by

world’s population by

2009 and representing half of the

2009 and representing half of the world’s

world’s

population by 2010.

•

• _{Collect surgical vital statistics for one}

_{Collect surgical vital statistics for one}

country in each WHO region by 2010

(26)

Easy Math

234 million people are operated on each

year, and >1 million of these individuals die

from complications

At least ½ are avoidable with the Checklist

500,000 lives on the line each

year

+

(27)

• • ChecklistChecklist • • BrochureBrochure • • FAQFAQ •

• How-to videosHow-to videos

• • ImplementationImplementation Manual Manual • • GuidelinesGuidelines •