Surgical Patient Safety Research Articles

Concurrent Surgical Patient Safety Indicator Evaluation Results in More Accurate Reporting and Reimbursement

We sought to determine whether concurrent (before discharge) Agency for Healthcare Research and Quality patient safety indicator evaluation would result in a more expeditious review, accurate reporting, and improved reimbursement. We compared the period of preconcurrent (preC) coding (January 2012 to June 2012) with the period after concurrent coding (postC) began (July 2012 to December 2012) for total billing errors. There were 276 records reviewed in the preC versus 424 in the postC time periods. Overall coding errors were 225 (81.5%) preC versus 365 (86.1%) postC (P = nonsignificant), whereas documentation errors were present in 26 (9.4%) preC versus 40 (9.4%) postC (P = nonsignificant). Total charges were $3,782,024 preC and $2,011,144 postC. Recodes requiring rebilling were 21 (7.6%) preC for a total of $213,723 rebilled versus four (0.9%) postC for a total of $31,327 rebilled (P < 0.0001). Time from service to review was 98.7 preC versus 52.3 postC days (P < 0.0001). Time from service until rebill submitted averaged 100.8 preC versus 54.0 postC days (P = 0.06). Concurrent review allows for more accurate reporting because recodes are completed before discharge. Billing delays prolong time to reimbursement and results in loss of revenue.

Implementación de un listado de verificación de prácticas seguras en cirugía: experiencia de la fase inicial de la puesta en marcha de un proyecto colaborativo en hospitales de Catalunya

Surgical patient safety is a priority in the national and international quality healthcare improvement strategies. The objective of the study was to implement a collaborative intervention with multiple components and to evaluate the impact of the patient surgical safety checklist (SSC) application.This is a prospective, longitudinal multicenter study with a 7-month follow-up period in 2009 based on a collaborative intervention for the implementation of a 24 item-SSC distributed in 3 different stages (sign in, time out, sign out) for its application to the surgical patient. A total number of 27 hospitals participated in the strategy.The global implementation rate was 48% (95%CI, 47.6%-48.4%) during the evaluation period. The overall compliance with all the items of the SSC included in each stage (sign in, time out, sign out) was 75,1% (95%CI, 73.5%-76.7%) for the sign in, 77.1% (95%CI, 75.5%-78.6%) for the time out and 88.3% (95%CI, 87.2%-89.5%) for the sign out respectively. The individual compliance with each item of the SSC has remained above 85%, except for the surgical site marking with an adherence of 67.4% (95%CI, 65.7%-69.1%)] and 71.2% (95%CI, 69.6%-72.9%)] in the sign in and time out respectively. The SSC was successfully implemented to 48% of the surgeries performed to the participating hospitals. The global compliance with the SSC was elevated and the intervention trend was stable during the evaluation period. Strategies were identified to allow of a higher number of surgeries with application of the SSC and more professional involvement in measures compliance such as surgical site marking.

The role of change agents in achieving quality improvement

Background Several UMCG-wide implementation projects improving quality and patient safety have been organized to stimulate the (intrinsic) motivation to work safely in order to bring about the intended change. We deployed ‘change agents’ in various involved groups of professionals and trained them in supporting and stimulating their colleagues to work safely according to the latest evidence based guidelines. We will discuss the effects on implementation success of this strategy, using three examples of improvement projects, namely the implementation of a screening instrument for elderly patients to identify frailty, the Surgical Patient Safety System checklist (SURPASS) in the perioperative process, and the guideline Personal Hygiene.

Disclosure of adverse events and errors in surgical care: challenges and strategies for improvement.

The disclosure of adverse events to patients, including those caused by medical errors, is a critical part of patient-centered healthcare and a fundamental component of patient safety and quality improvement. Disclosure benefits patients, providers, and healthcare institutions. However, the act of disclosure can be difficult for physicians. Surgeons struggle with disclosure in unique ways compared with other specialties, and disclosure in the surgical setting has specific challenges. The frequency of surgical adverse events along with a dysfunctional tort system, the team structure of surgical staff, and obstacles created inadvertently by existing surgical patient safety initiatives may contribute to an environment not conducive to disclosure. Fortunately, there are multiple strategies to address these barriers. Participation in communication and resolution programs, integration of Just Culture principles, surgical team disclosure planning, refinement of informed consent and morbidity and mortality processes, surgery-specific professional standards, and understanding the complexities of disclosing other clinicians' errors all have the potential to help surgeons provide patients with complete, satisfactory disclosures. Improvement in the regularity and quality of disclosures after surgical adverse events and errors will be key as the field of patient safety continues to advance.

The Image Gently Pediatric Digital Radiography Safety Checklist: Tools for Improving Pediatric Radiography

Transition from film-screen to digital radiography requires changes in radiographic technique and workflow processes to ensure that the minimum radiation exposure is used while maintaining diagnostic image quality. Checklists have been demonstrated to be useful tools for decreasing errors and improving safety in several areas, including commercial aviation and surgical procedures. The Image Gently campaign, through a competitive grant from the FDA, developed a checklist for technologists to use during the performance of digital radiography in pediatric patients. The checklist outlines the critical steps in digital radiography workflow, with an emphasis on steps that affect radiation exposure and image quality. The checklist and its accompanying implementation manual and practice quality improvement project are open source and downloadable at www.imagegently.org. The authors describe the process of developing and testing the checklist and offer suggestions for using the checklist to minimize radiation exposure to children during radiography.

Safe pediatric surgery: development and validation of preoperative interventions checklist

This study was aimed at developing and validating a checklist of preoperative pediatric interventions related to the safety of surgical patients. Methodological study concerning the construction and validation of an instrument with safe preoperative care indicators. The checklist was subject to validation through the Delphi technique, establishing a consensus level of 80%. Five professional specialists in the area conducted the validation and a consensus on the content and the construct was reached after two applications of the Delphi technique. The "Safe Pediatric Surgery Checklist", simulating the preoperative trajectory of children, is an instrument capable of contributing to the preparation and promotion of safe surgery, as it identifies the presence or absence of measures required to promote patient safety.

Allergic Reaction to a Red Plastic Allergy Alert Patient Identification Bracelet: Implications for Surgical Patient Safety

We present a case of allergy to a hospital thermally-printed red plastic allergy alert bracelet in a 48 year old lady admitted to the day surgery unit. Two hours postoperatively, an intensely itchy area of erythema and oedema was seen extending from her left wrist distally to the fingers. The bracelet was removed and the rash resolved overnight without further complication. A diagnosis of contact dermatitis was made, secondary to exposure to an agent within the bracelet. We discuss the safety implications for surgical patients unable to wear an identification bracelet and the steps that may be taken to minimise the risk of harm from misidentification. We believe this to be the first documented case of an allergy to a patient identification bracelet in the medical literature.

Holding the Scalpel

In this article, we show what surgical training looks like in situ. Drawing on fieldwork in a London hospital, we explore how a trainer and trainee jointly achieve surgical care when the trainee holds the scalpel. We make this common pedagogic arrangement visible through transcription and analysis of audio- and video-recorded interaction in the operating theater. Through moment-by-moment analysis of the temporal unfolding of action and speech, we show that the actions performed by the trainee with the scalpel serve as mini-gestures, signaling to the trainer where and when the trainee is going to cut. The trainer “reads” these gestures and prompts the trainee to continue or change his course of action through spoken utterances. We use our ethnographic account as a detailed empirical point of reference for reflecting on the challenges and possibilities of surgical education and patient safety in the operating theater.

Operating room data management: improving efficiency and safety in a surgical block

BackgroundEuropean Healthcare Systems are facing a difficult period characterized by increasing costs and spending cuts due to economic problems. There is the urgent need for new tools which sustain Hospitals decision makers work. This project aimed to develop a data recording system of the surgical process of every patient within the operating theatre. The primary goal was to create a practical and easy data processing tool to give hospital managers, anesthesiologists and surgeons the information basis to increase operating theaters efficiency and patient safety.MethodsThe developed data analysis tool is embedded in an Oracle Business Intelligence Environment, which processes data to simple and understandable performance tachometers and tables. The underlying data analysis is based on scientific literature and the projects teams experience with tracked data. The system login is layered and different users have access to different data outputs depending on their professional needs. The system is divided in the tree profile types Manager, Anesthesiologist and Surgeon. Every profile includes subcategories where operators can access more detailed data analyses. The first data output screen shows general information and guides the user towards more detailed data analysis. The data recording system enabled the registration of 14.675 surgical operations performed from 2009 to 2011.ResultsRaw utilization increased from 44% in 2009 to 52% in 2011. The number of high complexity surgical procedures (≥120 minutes) has increased in certain units while decreased in others. The number of unscheduled procedures performed has been reduced (from 25% in 2009 to 14% in 2011) while maintaining the same percentage of surgical procedures. The number of overtime events decreased in 2010 (23%) and in 2011 (21%) compared to 2009 (28%) and the delays expressed in minutes are almost the same (mean 78 min). The direct link found between the complexity of surgical procedures, the number of unscheduled procedures and overtime show a positive impact of the project on OR management. Despite a consistency in the complexity of procedures (19% in 2009 and 21% in 2011), surgical groups have been successful in reducing the number of unscheduled procedures (from 25% in 2009 to 14% in 2011) and overtime (from 28% in 2009 to 21% in 2011).ConclusionsThe developed project gives healthcare managers, anesthesiologists and surgeons useful information to increase surgical theaters efficiency and patient safety. In difficult economic times is possible to develop something that is of some value to the patient and healthcare system too.

The Bernese peri-acetabular osteotomy through a modified approach. A technical note

A modification of the technique for performing the Bernese periacetabular osteotomy is described. A medial approach to the Ischium and a subtle re-orientation of the pubic osteotomy are detailed. Surgical morbidity is likely decreased with a concurrent cosmetic advantage without compromise to surgical correction or patient safety.

&amp;nbsp;Patient safety in orthopedic surgery: prioritizing key areas of iatrogenic harm through an analysis of 48,095 incidents reported to a national database of errors

BackgroundWith scientific and technological advances, the practice of orthopedic surgery has transformed the lives of millions worldwide. Such successes however have a downside; not only is the provision of comprehensive orthopedic care becoming a fiscal challenge to policy-makers and funders, concerns are also being raised about the extent of the associated iatrogenic harm. The National Reporting and Learning System (NRLS) in England and Wales is an underused resource which collects intelligence from reports about health care error.MethodsUsing methods akin to case-control methodology, we have identified a method of prioritizing the areas of a national database of errors that have the greatest propensity for harm. Our findings are presented using odds ratios (ORs) and 95% confidence intervals (CIs).ResultsThe largest proportion of surgical patient safety incidents reported to the NRLS was from the trauma and orthopedics specialty, 48,095/163,595 (29.4%). Of those, 14,482/48,095 (30.1%) resulted in iatrogenic harm to the patient and 71/48,095 (0.15%) resulted in death. The leading types of errors associated with harm involved the implementation of care and on-going monitoring (OR 5.94, 95% CI 5.53, 6.38); self-harming behavior of patients in hospitals (OR 2.14, 95% CI 1.45, 3.18); and infection control (OR 1.91, 95% CI 1.69, 2.17). We analyze these data to quantify the extent and type of iatrogenic harm in the specialty, and make suggestions on the way forward.Conclusion and level of evidenceDespite the limitations of such analyses, it is clear that there are many proven interventions which can improve patient safety and need to be implemented. Avoidable errors must be prevented, lest we be accused of contravening our fundamental duty of primum non nocere. This is a level III evidence-based study.

Anesthetic Risks Associated With Antley-Bixler Syndrome

Antley-Bixler syndrome is an autosomal recessive disorder characterized by multiple bone and cartilaginous abnormalities. The main features of this syndrome include brachycephaly, midface hypoplasia, dysplasia of ears and nose, radiohumeral synostosis, choanal stenosis, or atresia. Distinctive features are based on craniofacial deformity and humeroradial synostosis. In this report, we describe the anesthesia management of a 20-year-old Antley-Bixler syndrome patient who underwent maxillary advancement via Le Fort I osteotomy. During surgical management of craniofacial syndrome patients, particularly Antley-Bixler syndrome, the whole surgical team should be aware of possible deformities involving the airway, which may be underestimated or nondetected prior to surgery. These deformities including choanal atresia/stenosis may lead to failure of nasotracheal intubation and mask ventilation, therefore jeopardizing the surgical procedure and/or patient safety. Accurate preoperative preparation and being aware of the components of this syndrome is vital to eliminate respiratory complications and enable uneventful anesthetic and surgical management.

Surgical Guides (Patient-Specific Instruments) for Pediatric Tibial Bone Sarcoma Resection and Allograft Reconstruction

To achieve local control of malignant pediatric bone tumors and to provide satisfactory oncological results, adequate resection margins are mandatory. The local recurrence rate is directly related to inappropriate excision margins. The present study describes a method for decreasing the resection margin width and ensuring that the margins are adequate. This method was developed in the tibia, which is a common site for the most frequent primary bone sarcomas in children. Magnetic resonance imaging (MRI) and computerized tomography (CT) were used for preoperative planning to define the cutting planes for the tumors: each tumor was segmented on MRI, and the volume of the tumor was coregistered with CT. After preoperative planning, a surgical guide (patient-specific instrument) that was fitted to a unique position on the tibia was manufactured by rapid prototyping. A second instrument was manufactured to adjust the bone allograft to fit the resection gap accurately. Pathologic evaluation of the resected specimens showed tumor-free resection margins in all four cases. The technologies described in this paper may improve the surgical accuracy and patient safety in surgical oncology. In addition, these techniques may decrease operating time and allow for reconstruction with a well-matched allograft to obtain stable osteosynthesis.

Critical Roles of Orthopaedic Surgeon Leadership in Healthcare Systems to Improve Orthopaedic Surgical Patient Safety

The prevention of medical and surgical harm remains an important public health problem despite increased awareness and implementation of safety programs. Successful introduction and maintenance of surgical safety programs require both surgeon leadership and collaborative surgeon-hospital alignment. Documentation of success of such surgical safety programs in orthopaedic practice is limited. We describe the scope of orthopaedic surgical patient safety issues, define critical elements of orthopaedic surgical safety, and outline leadership roles for orthopaedic surgeons needed to establish and sustain a culture of safety in contemporary healthcare systems. We identified the most common causes of preventable surgical harm based on adverse and sentinel surgical events reported to The Joint Commission. A comprehensive literature review through a MEDLINE(®) database search (January 1982 through April 2012) to identify pertinent orthopaedic surgical safety articles found 14 articles. Where gaps in orthopaedic literature were identified, the review was supplemented by 22 nonorthopaedic surgical references. Our final review included 36 articles. Six important surgical safety program elements needed to eliminate preventable surgical harm were identified: (1) effective surgical team communication, (2) proper informed consent, (3) implementation and regular use of surgical checklists, (4) proper surgical site/procedure identification, (5) reduction of surgical team distractions, and (6) routine surgical data collection and analysis to improve the safety and quality of surgical patient care. Successful surgical safety programs require a culture of safety supported by all six key surgical safety program elements, active surgeon champions, and collaborative hospital and/or administrative support designed to enhance surgical safety and improve surgical patient outcomes. Further research measuring improvements from such surgical safety systems in orthopaedic care is needed.

Laser Angiography as a Predictor of Mastectomy Flap Necrosis after Breast Reconstruction

Sir:FigureSkin-sparing mastectomy improves the aesthetic result of the reconstructed breast and broadens the reconstructive options. However, areas of ischemia leading to necrosis can prove difficult to clinically assess. We review our experience with laser angiography as a predictor of mastectomy skin flap necrosis. All women who were to undergo immediate postmastectomy breast reconstruction were candidates for this study. Women with an allergy to iodinated contrast dye were excluded. All mastectomy flaps in patients undergoing immediate breast reconstruction over a 2-year period were studied. The vascularity of each flap was initially assessed clinically, and simultaneous intraoperative images were obtained using infrared fluorescent tissue angiography (SPY SP2001; Novadaq, Mississauga, Ontario, Canada) with indocyanine green (Akorn, Inc., Buffalo Grove, Ill.). For performance of the indocyanine green angiography, 4 ml (2.5 mg/ml) of indocyanine green was infused through a peripheral intravenous catheter by the anesthesia personnel, followed by a 10-ml saline flush. Eight seconds after infusion, real-time fluorescent videoangiography of the mastectomy flaps was captured for 1 minute using the Novadaq SPY SP2001 imaging laser. Any portion of the mastectomy flaps that did not appear viable by clinical examination was excised. No tissue was excised based on indocyanine green fluorescence alone. Postoperatively, the amount of fluorescence (fluorescence level) throughout each saved image was calculated (SPY-Q; Novadaq), with relative percentages of fluorescent brightness noted when compared with the most well-perfused area of each respective flap (or brightest, regarded as 100 percent). The fluorescent images and respective postoperative photographs were then compared and areas of ischemic necrosis were correlated. Two hundred twenty-seven mastectomy flaps in 174 patients were studied. Poorly perfused mastectomy flap skin, as determined clinically, was resected. However, mastectomy flap necrosis occurred in 10 breasts (4.41 percent). Four of the 10 (40 percent) developed full-thickness necrosis requiring débridement, and the remaining six breasts (60 percent) developed partial-thickness necrosis and healed with conservative care. However, all areas of necrosis displayed a fluorescence level of 18 percent or less (positive predictive value, 100 percent) (Figs. 1 and 2). All reconstructions were salvaged using the original procedure.Fig. 1: Intraoperative laser image of left mastectomy flaps showing areas with a fluorescence level less than 18 percent (blue circled islands).Fig. 2: Postoperative necrosis correlating to Figure 1.Because of its reliable intravascular pattern and its ability to be used multiple times in a single operation, indocyanine green with near-infrared fluorescence has gained increased utility in plastic surgery. Many large-volume clinical studies have supported its use in breast surgery, ranging from breast reduction, to mastectomy flap assessment, to breast reconstruction.1–5 In addition, although plastic surgery will likely remain largely objective in technique and outcome, objective determination of meaningful tissue ischemia may help decrease reoperation rates and ultimately improve surgical outcomes and patient safety. In our study, we determined that a relative fluorescence level of 18 percent or less predicted partial- or full-thickness mastectomy flap necrosis. We also found that comorbid medical conditions, such as exposure to radiation and smoking, positively correlated to necrosis depth. John D. Murray, M.D. Glyn E. Jones, M.D. Eric T. Elwood, M.D. Lisa A. Whitty, M.D. Chris Garcia, B.S. University of Illinois College of Medicine at Peoria, Peoria, Ill. DISCLOSURE The authors have no financial interest in any of the products or devices mentioned in this article.

Nature and timing of incidents intercepted by the SURPASS checklist in surgical patients

IntroductionMore than half of in-hospital adverse events can be attributed to a surgical discipline. Checklists can effectively decrease errors and adverse events. However, the mechanisms by which checklists lead to...

Morbidity in surgery: impact of the 50-hour work-week limitation in Switzerland

Work-hour regulations for residency programmes in Switzerland, including a 50-hour weekly limit, were set in on 1 January 2005. Patient safety was one of the major arguments for the implementation. As the effect of the restriction of residency work hours on patient care in Switzerland has not yet been evaluated on objective data, the aim of the present study was to assess its impact by comparing the patients' morbidity and mortality before (2001-2004) and after (2005-2008) the implementation. Retrospective analysis of records of the Spitalzentrum Biel AG, a large referral center classified according to the Swiss Medical Association, collected in the database of the Association for Quality Assurance in Surgery (AQC), a prospective database of consecutive patients undergoing surgical procedures in Switzerland. A selection of 2,686 patients with common surgeries, operated on by residents, was performed. There were 1,259 (46.9%) patients meeting our inclusion criteria who were admitted during the period before introduction of work-hour limitation and 1,427 (53.1%) patients after introduction. The in-hospital mortality and postoperative surgical complication rate were significantly higher after the reform (p <0.05 and p <0.01, respectively). No significant differences could be found concerning the overall intraoperative (p = 0.61) and postoperative medical complication frequencies (p = 0.08). The work-hour limitation implemented in Switzerland was not associated with surgical patient safety measure improvement for common surgeries (i.e., morbidity and mortality rate). Further research on a nationwide basis is needed to assess the value of the higher surgical complication and mortality rate.

Thinking in three's: Changing surgical patient safety practices in the complex modern operating room

The three surgical patient safety events, wrong site surgery, retained surgical items (RSI) and surgical fires are rare occurrences and thus their effects on the complex modern operating room (OR) are difficult to study. The likelihood of occurrence and the magnitude of risk for each of these surgical safety events are undefined. Many providers may never have a personal experience with one of these events and training and education on these topics are sparse. These circumstances lead to faulty thinking that a provider won't ever have an event or if one does occur the provider will intuitively know what to do. Surgeons are not preoccupied with failure and tend to usually consider good outcomes, which leads them to ignore or diminish the importance of implementing and following simple safety practices. These circumstances contribute to the persistent low level occurrence of these three events and to the difficulty in generating sufficient interest to resource solutions. Individual facilities rarely have the time or talent to understand these events and develop lasting solutions. More often than not, even the most well meaning internal review results in a new line to a policy and some rigorous enforcement mandate. This approach routinely fails and is another reason why these problems are so persistent. Vigilance actions alone have been unsuccessful so hospitals now have to take a systematic approach to implementing safer processes and providing the resources for surgeons and other stakeholders to optimize the OR environment. This article discusses standardized processes of care for mitigation of injury or outright prevention of wrong site surgery, RSI and surgical fires in an action-oriented framework illustrating the strategic elements important in each event and focusing on the responsibilities for each of the three major OR agents-anesthesiologists, surgeons and nurses. A Surgical Patient Safety Checklist is discussed that incorporates the necessary elements to bring these team members together and influence the emergence of a safer OR.

The 5th anniversary of “Patient Safety in Surgery” – from the Journal’s origin to its future vision

Inception of a new journal “Patient Safety in Surgery” (PSS) was launched on November 7, 2007, as the first and only open-access, peer-reviewed, PubMed-cited online journal in the field of surgical patient safety [1]. Five years later, PSS remains the sole journal devoted to patient safety issues in surgery. The conception of the Journal’s mission originated in the summer of 2006 with a group of surgeon colleagues brain-storming about the meaning of the dogma that “good judgment comes from experience which comes from poor judgment”. During our routine weekly morbidity and mortality conferences in Denver and Zurich, we regularly unraveled severe complications generated by younger colleagues on their “learning curve”. Unfortunately, the patient is the one who eventually pays the price for the individual surgeon’s experience. We speculated about new options for sharing root causes of preventable incidents and complications, in order to avoid similar events to re-occur in a different patient in a different hospital. This fruitful debate led to the brainchild of creating a new international “forum” for exchanging case scenarios of specific surgical complications. This forum should be easily accessible, and include discussion of root causes, preventability, and action items needed for resolution and prevention of the future re-occurrence of identical, or similar, adverse events. Our debate also scrutinized the tendency of most standard print journals to publish positive data exclusively, with little room for negative results and reports on surgical failures and poor patient outcomes [2]. In a united consensus, we reasoned that the best option for creating a new forum of unrestricted reporting and debate on quality of care issues in the perioperative

Building global capacity for patient safety: A training program for surgical safety research in developing and transitional countries

BackgroundRecent studies show a significant rate of adverse events in hospitalized patients in developing/transitional countries – with approximately 18% of them related to surgical procedures. Understanding and preventing these errors requires adequate training in patient safety research methods – however, relevant training programs are currently lacking. We developed, delivered and evaluated a training program to address this gap. MethodsA one-day training program was developed based on the recently published WHO core competencies for patient safety research. The focus was on surgical patient safety research – including human factors, operating room (OR) teamwork, the OR environment, and safety culture. Feasibility, relevance and preliminary evaluation of the program (‘proof of concept’ testing) was conducted in Bogotá, Colombia in July 2011. A validated evaluation framework was utilized, assessing participants' objective knowledge, attitudes, and observational skills. Results30 postgraduate students from a range of clinical/non-clinical disciplines signed up and 17 attended the program. Participants' knowledge of surgical patient safety significantly improved upon program completion (Mean pre-course = 55% vs. Mean post-course = 68%, P < 0.01), as did their confidence and understanding of problems and methodologies to assess OR patient safety, and teamwork issues (P < 0.05). Observational skills in recognizing safety-related behaviors using OTAS (i.e., quality of teamwork) improved on qualitative evaluation. ConclusionsWe have developed a viable, WHO-driven training program that can be delivered to clinical and non-clinical researchers to develop their competencies and thereby build capacity in developing/transitional countries to carry out surgical safety research. All program materials are available in English and Spanish for research, training and dissemination.