WHO Safe Surgery Research Articles

Pulse oximeter provision and training of non-physician anesthetists in Zambia: a qualitative study exploring perioperative care after training

BackgroundPulse oximetry monitoring is included in the WHO Safe Surgery Checklist and recognized as an essential perioperative safety monitoring device. However, many low resource countries do not have adequate numbers of pulse oximeters available or healthcare workers trained in their use. Lifebox, a nonprofit organization focused on improving anesthetic and surgical safety, has procured and distributed pulse oximeters and relevant educational training in over 100 countries. We aimed to understand qualitatively how pulse oximetry provision and training affected a group of Zambian non-physician anesthetists’ perioperative care and what, if any, capacity gaps remain.MethodsWe identified and approached non-physician anesthetists (NPAPs) in Zambia who attended a 2019 Lifebox pulse oximetry training course to participate in a semi-structured interview. Interviews were audio recorded and transcribed. Codes were iteratively derived; the codebook was tested for inter-rater reliability (pooled kappa > 0.70). Team-based thematic analysis identified emergent themes on pulse oximetry training and perioperative patient care.ResultsTen of the 35 attendees were interviewed. Two themes emerged concerning pulse oximetry provision and training in discussion with non-physician anesthetists about their experience after training: (1) Impact on Non-Physician Anesthetists and the Healthcare Team and (2) Impact on Perioperative Patient Monitoring. These broad themes were further explored through subthemes. Increased knowledge brought confidence in monitoring and facilitated quick interventions. NPAPs reported improved preoperative assessments and reaffirmed the necessity of having pulse oximetry intraoperatively. However, lack of device availability led to case delays or cancellations. A portable device travelling with the patient to the recovery ward was noted as a major improvement in postoperative care. Pulse oximeters also improved communication between nurses and NPAPs, giving NPAPs confidence in the recovery process. However, this was not always possible, as lack of pulse oximeters and ward staff unfamiliarity with oximetry was commonly reported. NPAPs expressed that wider pulse oximetry availability and training would be beneficial.ConclusionAmong a cohort of non-physician anesthetists in Zambia, the provision of pulse oximeters and training was perceived to improve patient care throughout the perioperative timeline. However, capacity and resource gaps remain in their practice settings, especially during transfers of care. NPAPs identified a number of areas where patient care and safety could be improved, including expanding access to pulse oximetry training and provision to ward and nursing staff to ensure the entire healthcare team is aware of the benefits and importance of its use.

Patient safety during anesthesia in Ukraine: national audit results

BackgroundAlthough anesthesiologists are one of the leaders in patient safety, anesthesia in low and low-middle income countries still need improvement in safety mesures with evidence-based practice application. The study aim was to audit the safety principles implementation in the Ukrainian anesthesiologist`s practice.MethodsThe study was held in March 2021-Februrary 2022 by filling out an online questionnarie. The link to the survey was distributed through Ukrainian Anesthesiologists Association (UAA) members emails and also published on UAA webpage and facebook page. The email was sent to 1000 UAA members.ResultsSummary 210 respondents took part in the study. Among the respondents, 79.1% of respondents are aware of the Helsinki Declaration on Patient Safety in Anesthesiology, but only 40,3% declared that the principles of this Declaration had been implemented in their medical institutions. Even though most of the respondents declared that the quality of the work has improved with the application of the Helsinki Declaration, 16% stated, that there is no positive impact.Most of the medical institutions include mandatory perioperative monitoring, while 17% of hospitals have no access to pulse oximetry for all patients in the operating room and intensive care unit. Concerning using clinical protocols, the one on the treatment of massive bleeding is used in 60.3% of cases, on infection control in 60.5%.In relation to checklists, 28.2% of respondents have never heard about the WHO Safe Surgery checklist. Checklists for equipment inspection are used in only 27.8% of medical institutions. 72.8% hospitals keep records of anaesthesia complications.ConclusionThe study showed that significant positive steps are being taken to improve patient safety in Ukraine, where most hospitals comply with the minimum standarts of monitoring during anesthesia. Although there are many challenges for improvement, more hospitals need to implement WHO Safe Surgery and equipment checklists, protocols etc. These areas are a priority for further development in Ukraine.Trial registrationClinicaltrials.gov NCT05175976 on 04/01/2022.

Knowledge, attitudes and practices regarding patient safety among surgical trainees in Sri Lanka

IntroductionSurgical trainees play an integral role in the perioperative workup and safety of patients undergoing surgery. This study was aimed to assess surgical trainees’ knowledge, attitudes and practices on perioperative surgical patient safety. MethodsA descriptive cross-sectional study among 105 surgical trainees (males 96%, mean age 33 years, range 30-40 years) was performed using self-administered validated questionnaires on knowledge, attitudes (Safety Attitude Questionnaire-SAQ) and practices (Questionnaire on evidence-based safety practices and reporting of medical errors). Responses were marked on a 5-point Likert scale and were analysed.ResultsApproximately two thirds (n=72, 69%) were junior registrars and the rest (n=33, 31%) were senior registrars. The median knowledge score was 60 (range 10-90). The Median SAQ score was 74 (151/205, range 57-95). Approximately 65% (n=68) claimed they were aware of the protocols of marking the surgical site. Nearly three quarters (n=78, 74%) have read the WHO safe surgery guidelines. Eighty-seven participants (84%) had not attended a formal risk management course/ teaching activity. Only 53% (n=56) believed that medical errors were handled appropriately and less than a third (31%, n=33) believed that the work environment was favourable to discuss errors. Only 54% (n=57) had received appropriate feedback about their performances. ConclusionOverall, the patient safety culture among surgical trainees was found to be suboptimal. Formal teaching sessions, workshops and local guidelines may help improve knowledge and attitudes on patient safety among surgical trainees. Furthermore, working conditions need to be improved to encourage discussion of medical errors and allow frequent feedback.

Evaluation of the Introduction of a Colorectal Bundle in Left Sided Colorectal Resections (EvaCol): Study Protocol of a Multicentre, Observational Trial.

Purpose:Overall complication and leak rates in colorectal surgery showed only minor improvements over the last years and remain still high. While the introduction of the WHO Safer Surgery Checklist has shown a reduction of overall operative mortality and morbidity in general surgery, only minor attempts have been made to improve outcomes by standardizing perioperative processes in colorectal surgery. Nevertheless, a number of singular interventions have been found reducing postoperative complications in colorectal surgery. The aim of the present study is to combine nine of these measures to a catalogue called colorectal bundle (CB). This will help to standardize pre-, intra-, and post-operative processes and therefore eventually reduce complication rates after colorectal surgery.Methods:The study will be performed among nine contributing hospitals in the extended north-western part of Switzerland. In the 6-month lasting control period the patients will be treated according to the local standard of each contributing hospital. After a short implementation phase all patients will be treated according to the CB for another 6 months. Afterwards complication rates before and after the implementation of the CB will be compared.Discussion:The overall complication rate in colorectal surgery is still high. The fact that only little progress has been made in recent years underlines the relevance of the current project. It has been shown for other areas of surgery that standardization is an effective measure of reducing postoperative complication rates. We hypothesize that the combination of effective, individual components into the CB can reduce the complication rate.Trial registration:Registered in ClinicalTrials.gov on 11/03/2020; NCT04550156.Highlights Purpose: Overall complications in colorectal surgery remain still highStandardizing can reduce overall operative mortality and morbidityOnly minor attempts have been made to standardize perioperative processes in colorectal surgerySingular interventions have been found reducing postoperative complicationsThe aim is to combine nine of these measures to a colorectal bundle (CB)The CB will help to reduce complication rates after colorectal surgery Methods: The observational study will be performed among nine hospitals in SwitzerlandSix month the patients will be treated according to the local standardsAfterwards patients will be treated according to the CB for another six monthsComplication rates before and after the implementation of the CB will be compared Discussion: Only little progress has been made to reduce complication rate in colorectal surgeryStandardization is an effective measure of reducing complication ratesThe combination of effective, individual components into the CB can reduce the complication rate

Barriers and Facilitators of Implementing WHO Safe Surgery Checklist: A Cross-sectional Study in Public Hospitals of Iran

Background: The implementation of WHO safe surgery checklist (SSC) was proposed by the Ministry of Health and Medical Education in the operation rooms of Iranian hospitals in 2011, but was canceled after several years due to some challenges in implementation. Objectives: This study aimed to investigate the barriers and facilitators of the effective implementation of the SSC. Methods: This cross-sectional study was performed in public hospitals of Tabriz city in 2019. The study population consisted of operation room working staff, and the purposive sampling was used. The research tool was a researcher-made questionnaire designed through literature review and included three parts of demographic variables, barriers, and facilitating factors. Data were analyzed with SPSS-22. Results: The mean of barriers to implementation of the SSC was 3.03 out of 5. The most important barrier to implementing the checklist was the weakness in team working (3.18), while checklist barriers were the least important (2.98). The mean score of facilitating factors was 3.46. Among the facilitators, the highest score was for team working facilitators with a score of 3.47 and the lowest score was for the facilitators associated with the checklist with a score of 3.37. Conclusions: This is one of the first studies that explored the barriers and facilitators of SSC implementation in Iranian hospitals. We identified weak team working as the most important barrier to implementing the checklist. These results help policymakers and hospital managers to implement the checklist more effectively.

The Impact of Quality Improvement Interventions in Improving Surgical Infections and Mortality in Low and Middle‐Income Countries: A Systematic Review and Meta‐Analysis

Morbidity and mortality in surgical systems in low- and middle-income countries (LMICs) remain high compared to high-income countries. Quality improvement processes, interventions, and structure are essential in the effort to improve peri-operative outcomes. A systematic review and meta-analysis of interventional studies assessing quality improvement processes, interventions, and structure in developing country surgical systems was conducted according to the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were included if they were conducted in an LMIC, occurred in a surgical setting, and measured the effect of an implementation and its impact. The primary outcome was mortality, and secondary outcomes were rates of rates of hospital-acquired infection (HAI) and surgical site infections (SSI). Prospero Registration: CRD42020171542. Of 38,273 search results, 31 studies were included in a qualitative synthesis, and 28 articles were included in a meta-analysis. Implementation of multimodal bundled interventions reduced the incidence of HAI by a relative risk (RR) of 0.39 (95%CI 0.26 to 0.59), the effect of hand hygiene interventions on HAIs showed a non-significant effect of RR of 0.69 (0.46-1.05). The WHO Safe Surgery Checklist reduced mortality by RR 0.68 (0.49 to 0.95) and SSI by RR 0.50 (0.33 to 0.63) and antimicrobial stewardship interventions reduced SSI by RR 0.67 (0.48-0.93). There is evidence that a number of quality improvement processes, interventions and structural changes can improve mortality, HAI and SSI outcomes in the peri-operative setting in LMICs.

Patient safety and the role of the Helsinki Declaration on Patient Safety in Anaesthesiology

The Helsinki Declaration on Patient Safety was launched in 2010 by the European Society of Anaesthesiology and the European Board of Anaesthesiology. It is not clear how widely its vision and standards have been adopted. To explore the role of the Helsinki Declaration in promoting and maintaining patient safety in European anaesthesiology. Online survey. A total of 38 countries within Europe. Members of the European Society of Anaesthesiology who responded to an invitation to take part by electronic mail. Responses from a 16-item online survey to explore each member anaesthesiologist's understanding of the Declaration and compliance with its standards. We received 1589 responses (33.4% response rate), with members from all countries responding. The median [IQR] response rate of members was 20.5% [11.7 to 37.0] per country. There were many commonalities across Europe. There were very high levels of use of monitoring (pulse oximetry: 99.6%, blood pressure: 99.4%; ECG: 98.1% and capnography: 96.0%). Protocols and guidelines were also widely used, with those for pre-operative assessment, and difficult and failed intubation being particularly popular (mentioned by 93.4% and 88.9% of respondents, respectively). There was evidence of widespread use of the WHO Safe Surgery checklist, with only 93 respondents (6.0%) suggesting that they never used it. Annual reports of measures taken to improve patient safety, and of morbidity and mortality, were produced in the hospitals of 588 (37.3%) and 876 (55.7%) respondents, respectively. Around three-quarters of respondents, 1216, (78.7%) stated that their hospital used a critical incident reporting system. Respondents suggested that measures to promote implementation of the Declaration, such as a formal set of checklist items for day-to-day practice, publicity, translation and simulation training, would currently be more important than possible changes to its content. Many patient safety practices encouraged by the Declaration are well embedded in many European countries. The data have highlighted areas where there is still room for improvement.

Commentary on: ‘The WHO safer surgery checklist time out procedure revisited: Strategies to optimise compliance and safety’

Commentary on: ‘The WHO safer surgery checklist time out procedure revisited: Strategies to optimise compliance and safety’

The WHO safer surgery checklist time out procedure revisited: Strategies to optimise compliance and safety.

It is human nature to make mistakes, all people in all works make errors, but an amputation of the wrong leg or an inadvertently retained needle in the abdominal cavity are unanticipated incidents, that no physician in the world wants to experience. Such catastrophic events, except for the consequences on the patient's health and the physician's career, have severe financial implications on the healthcare system. Human nature, apart from making mistakes, is also able to find solutions to minimize adverse incidents. A systematic time-out in the operating room just before incision has been introduced the last two decades to help prevent wrong site surgeries and other surgical never events. Despite its effectiveness in increasing patient safety, compliance issues remain a major problem in its implementation and gaps in its daily use still occur. The current review presents patterns of wrong time-out procedures, emphasizes the problem of poor compliance and reviews the suggested strategies to increase compliance for safer operating rooms.

Why are patients not more involved in their own safety? A questionnaire-based survey in a multi-ethnic North London hospital population

PurposeActive patient participation in safety pathways has demonstrated benefits in reducing preventable errors, especially in relation to hand hygiene and surgical site marking. The authors sought to examine patient participation...

Incidence, root cause, and outcomes of unintentionally retained intraabdominal surgical sponges: a retrospective case series from two hospitals in Togo

BackgroundThe term gossypiboma refers to a sponge that has been forgotten in the surgical field. It is the most common retained surgical item, and constitutes a continuing problem for surgical safety. We performed a hospital-based study to examine their incidence, root cause, and outcomes, as an effort toward improving prevention.MethodsThis retrospective study covered 10 years (2006-2015) and included surgically confirmed cases of abdominal gossypibomas occurring after 45,011 abdominal and gynaecological operations in 2 public hospitals in Lome (Togo). Age, diagnosis, initial surgical procedure, evidence of textile count, and data related to the revision procedure were collected for descriptive analysis.ResultsFifteen cases of gossypibomas (11 women and 4 men) were recorded. The mean age of the patients was 27 (range 21-55) years. Initial procedures were gynaecological in 11 patients and 5 cases involved an emergency surgery. Evidence of sponge counting was found in 6cases. Gossypiboma was an incidental finding in 1 patient. The average time to onset of symptoms after the initial procedure was 2 months. The gossypiboma was removed within 7 days to 4 years after the initial procedure. Postoperative complications included enterocutaneous fistula in 2 patients, incisional hernia in 2 patients, and wound sepsis in 1 patient. Death occurred in 2 patients (13.3%).ConclusionsAlthough rare, the incidence of gossypibomas is still unacceptably high and reveals failures regarding patient safety standards. The associated morbidity and mortality are significant, yet can be reduced by an early diagnosis in the immediate postoperative period. A systematic methodical count of sponges is the cornerstone of prevention, and introducing surgical safety protocols, such as the WHO Safe Surgery Saves Lives checklist, can enhance effectiveness. There is a crucial need for safety-focused policies, which may include a never event reporting system, elaboration of prevention strategies, interventions, and evaluation.

Compliance with WHO safe surgery checklist in operating rooms: A case study in Iran Hospitals

Compliance with WHO safe surgery checklist in operating rooms: A case study in Iran Hospitals

WHO Safer Surgery checklist compliance amongst paediatric emergency plastic surgery patients in an UK hospital.

IntroductionThe WHO Safer Surgery checklist has become an important component of perioperative safety. Our objective, was to determine the compliance of completing the checklist for paediatric emergency plastic surgery patients at our unit.MethodsAn initial baseline was performed with 70 patients over two months at our unit. Following this, we raised awareness at an audit meeting and closed the audit loop using 80 patients over two months. The audit is reported in line with SQUIRE 2.0 criteria.ResultsInitial compliance was 88% overall and this increased to 91% post-intervention. Compliance with the individual stages in both cycles was for sign-in: 85%–86%, for time-out 92%–98% and for sign-out 86%–89%. Around one in four checklists were not scanned in both periods.ConclusionThis audit showed a high overall level of compliance in the checklists that were scanned and available for scrutiny. We have identified the areas that most need improvement and suggest ways for doing so.

Improving Surgical and Anaesthesia Practice: Review of the Use of the WHO Safe Surgery Checklist in Felege Hiwot Referral Hospital, Ethiopia

Development of surgical and anaesthetic care globally has been consistently reported as being inadequate. The Lancet Commission on Global Surgery highlights the need for action to address this deficit. One...

Peer review report 1 on “WHO Safer Surgery Checklist Compliance amongst Paediatric Emergency Plastic Surgery Patients in an UK Hospital”

Peer review report 1 on “WHO Safer Surgery Checklist Compliance amongst Paediatric Emergency Plastic Surgery Patients in an UK Hospital”

Peer review report 2 on “WHO Safer Surgery Checklist Compliance amongst Paediatric Emergency Plastic Surgery Patients in an UK Hospital”

Peer review report 2 on “WHO Safer Surgery Checklist Compliance amongst Paediatric Emergency Plastic Surgery Patients in an UK Hospital”

Is Communication Improved With the Implementation of an Obstetrical Version of the World Health Organization Safe Surgery Checklist?

Communication failures are consistently seen as a root cause of preventable adverse outcomes in obstetrics. We assessed whether use of an Obstetric Safe Surgery Checklist for cesarean deliveries (CDs), based on the WHO Safe Surgery Checklist, can improve communication; reduce team member confusion about urgency of the case; and decrease documentation discrepancies among nursing, obstetric, anesthesia, and pediatric staff. Retrospective review of 600 CDs on our 2 labor and delivery suites before and after the introduction of 2 consecutive versions of our obstetric safe surgery checklist (100 cases in each cohort) was undertaken. The first version was released in 2010, and after modifications based on initial findings, our current version was released in 2014. One hundred consecutive CDs were identified from each of the 3 periods at each hospital, and charts for those patients and newborns were abstracted. Notes by obstetricians, nurses, anesthesiologists, and pediatricians were reviewed. We compared the rates of agreement in the documentation of the indication for the CD between the different members of the team. Chi-square analyses were performed. Complete agreement among the 4 specialties in the documented indication for CD before introduction of our initial safe surgery checklist was noted in 59% (n = 118) of cases. After initial checklist introduction, agreement decreased to 43% (n = 86; P = 0.002). We then modified our checklist to include indication for CD and level of urgency and changed our policy to include pediatric staff participation in the timeout. Agreement in a subsequent chart review increased to 80% (n = 160), significantly better than in our initial analysis (P < 0.001) and our interim review (P < 0.001). The greatest improvement in agreement was observed between obstetricians and pediatricians. Implementation of a safe surgery checklist can improve communication at CDs, but care should be taken when implementing checklists because they can have unanticipated consequences. Ongoing review and modification are critical to ensure safer medical care.

We need to talk about error: causes and types of error in veterinary practice

Patient safety research in human medicine has identified the causes and common types of medical error and subsequently informed the development of interventions which mitigate harm, such as the WHO's...

Using cardiac output monitoring to guide perioperative haemodynamic therapy.

The aim of this study was to review recent advances and evidence for the use of cardiac output monitors to guide perioperative haemodynamic therapy. There are multiple different cardiac output monitoring devices available for clinical use which are coupled with many different intervention protocols to manipulate perioperative haemodynamics. There is little evidence to demonstrate superiority of any one device. Previous small studies and meta-analyses have suggested that perioperative haemodynamic therapy guided by cardiac output monitoring improves outcomes after major surgery. Despite relatively low-quality evidence several national bodies have recommended 'perioperative goal-directed therapy' (GDT) as a standard of care.Recent larger trials of GDT have mostly failed to prove a benefit of GDT and one explanation for this is the increased quality of usual care that may be occurring because of initiatives such as enhanced recovery after surgery and the WHO Safer Surgery programmes. Perioperative GDT remains an exciting intervention to reduce significant morbidity following major surgery; however, it is not yet a proven standard of care. Further large pragmatic trials are required to demonstrate its effectiveness particularly in the era of enhanced recovery after surgery programmes.

Abstract 247: The Use of a World Health Organisation Derived Safe Surgery Checklist to Improve Patient Experience in the Cardiac Catheterisation Laboratory

Background: The WHO safe surgery checklist has reduced morbidity and mortality during surgery. Whether or not a modified WHO checklist could improve patient and staff experience in the cardiac catheterisation laboratory (CCL), where the majority of procedures are carried out under local anaesthetic, has not previously been investigated. Methods: Starting in March 2013, a WHO-derived checklist, specifically modified for the CCL, was introduced at the Royal Brompton Hospital. For three months, weekly PDSA cycles and staff feedback were used to optimise checklist design, followed by a full rollout. Patient experience (n=76, taken throughout the six-month period) and staff safety climate (taken 2 and 7 months after checklist introduction) surveys were undertaken to measure subjective impact. Clinical outcomes and efficiency data were obtained from in-house databases. Results: • By six months, a full checklist (Figure 1) was completed in 367/417 (88%) of procedures (Figure 2). Patient surveys revealed that the majority of patients (57%) noticed the staff ‘Time Out’ and when questioned, strongly associated the checklist with safety (mean score 9.3/10 using Likert scale) and found it highly reassuring (mean 8.9/10). • The majority of procedures that used the checklist (56%) were shorter than average, whereas the majority of procedures that did not use a checklist took longer than average (P&lt;0.0001) • When the full checklist was used, screening time was correspondingly reduced in 25% more procedures Conclusions: The introduction of a WHO-derived checklist was associated with high levels of patient satisfaction, improved efficiency, and enhance team cohesion during procedures in the cardiac catheterisation laboratory.