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Improving Patient Safety in the Dutch OR’s Johan Lange Department of Surgery Erasmus University Medical Center Rotterdam. Historical development crtitical success factors in surgery. factor. Results. Best practices, protocols (patientsafety ). Risk factors pati ent. medication
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Improving Patient Safety in the Dutch OR’sJohan LangeDepartment of Surgery Erasmus University Medical Center Rotterdam
Historical development crtitical success factors in surgery factor Results Best practices, protocols (patientsafety) Risk factors patient medication (anesthetics, AB, heparin) Professional training instruments&apparatus 0 21st century
Patient safety in the Netherlands (reports) • To err is human (Institute of Medicine 1999) • Hier werk je veilig, of je werkt hier niet (VMS; Rein Willems 2004) • TOP I (toezicht preoperatief proces/registratie; IGZ 2007) • Het resultaat telt (prestatieindicatoren IGZ) • Uitgeteld? (Meijsen, Meers 2007) • Voorkom schade, werk veilig (OMS, NVZ, LEVV 2007) • Koers op kwaliteit (VWS 2007) • TOP II (toezicht peroperatief proces/registratie; IGZ 2008) • Adviesrapport Cie Patiëntveiligheid NVvH
Adverse events in the Dutch OR (2005) • 45000 adverse events in 1.000.000 operations/year (all specialisms) • 25000 adverse events in surgery: 2.5% of operations • 10.000 adverse events in surgery: avoidable • Probably only 25% is reported • 400 mortal adverse events in the OR • 130 mortal adverse events in surgery • 40%: avoidable: 50 avoidable death in surgery/year -Report ‘Onbedoelde schade in de Nederlandse ziekenhuizen (Emgo/NIVEL 2007) -Cuperus-Bosma JM et al. NTvG 2005; 149: 2153-6
Adverse events in surgery • 36% of all adverse events in health care • Avoidable: 40% • >50%: related to the individual surgeon
Incidents in aviation: ‘75% (human factors)-rule’ • accident-analysis, blackbox, simulator-research: ‘75% rule’: 75% of incidents caused by teamwork-failure (human factors, chain of errors, human performance limitation)
Teamwork: shared mental model • Team situational awareness by: • Sharing knowledge: Goals Tasks Responabilities • Free flow of information among crew menbers, without fear of reservation (beware of dependance and hierarchy)
CRM (Crew Resource Management) • Obligation: Joint Aviation Requirements • Coaching instead of autocratic leadership • Leader-follower roles • Cross checking (briefing/debriefing, checklists) • Intervision/peer assessment (blame free-reporting)
Report ‘To err is human’Institute of Medicine USA 1999 "The experiences of other industries provide valuable insight about how to begin the process of improving safety of health care by learning how to prevent, detect, recover and learn from accidents."
VWS-Report ‘Here you are working safely, or you do not work here at all’‘The safety of Care’ 2004 • Recommendations: 1) Safety management system in all hospitals (VMS) • Blamefree incident-reporting
VWS-Report ‘Here you are working safely, or you do not work here at all’‘The safety of Care’ 2004Rein Willems (CEO Shell) • Recommendations: 1) Safety management system in all hospitals (VMS) • Blamefree incident-reporting
Teamwork in the OR • OR nurses are dissatisfied with communication in the OR • Nestel D, Kidd J. BMC Nursing 2006; 5:1 Feeling like a team member: • 75% of surgeons • 53% of residents • 45% of anesthesiologists • 23% of OR-nurses
Ongoing taboos in the OR • Failability of the surgeon • Horizontal communication • Mistakes (Culture of Name , Blame and Shame)
Communication: conflicts • Conflict between doctors: in 50% of hospitals • Conflicts with or within other professions: 36% Emmeloord/Lelystad Meppel Nijmegen Utrecht Source: L.A.P. Arends, i-BMG Erasmus University 2004
CRM: new leadership in the OR-team • Open communication • Coaching/Bindend/Sharing • Applying protocols and S.O.P.’s • Blamefree reporting
Professor Rhona Flin (Aberdeen)Behavioural marker observation system for teamwork
Advantages teambuilding/CRM (non technical-skills) • Respect and trust • Horizontal communication • Sharing knowledge and targets • Coaching/binding/sharing leadership • Cross checking (protocols, S.O.P.’s) • Peer assessment • Culture of transparancy (blamefree reporting) • Improved climate
Teamperformance: CRM + expertise (scenario-based simulation)
Teamperformance: CRM + expertise (scenario-based simulation)
Joint Commission on Accreditation of Healtcare Organizations (JCAHO) Universal Protocol for eliminating wrong site-, wrong procedure-, wrong person-surgery • Time Out-Procedure • Right side surgery • Type of procedure (protocol) • Identification patient
TOP (Time Out Procedure)+ Johan Lange, Linda Wauben, Conny Dekker, Geert Kazemier, Jan Klein, Jeroen PetersDepartments of Anesthesiology and Surgery Erasmus MC
Duration 1-2’ Compliance high In 15% of operations incidents can be avoided Anesthiology assistant: director Results pilot TOP+
Time Out=double check Time-Out
SURPASS (SURgical PAtient Safety System) –perioperative checklist • Validated (Marja Boermeester) • Transfermoments (ward-holding-OR) • Stopping rules
Teamwork (CRM): culture shock/paradigma shift • Transforming individual professionals into a professional team • Changing training/medical education • New shared responsabilities • New professional relationships
Short term-vision: Bureaucracy-reflex model Regulations Audit Long term-vision Regulations Audit Transparance Teamconcept Patient safety in the OR: planning
Historical development crtitical success factors in surgery factor Results Best practices, protocols (patientsafety) Risk factors patient medication (anesthetics, AB, heparin) Professional training instruments&apparatus 0 21st century
Historical development crtitical success factors in surgery factor Teamwork! Results Best practices, protocols (patientsafety) Risk factors patient medication (anesthetics, AB, heparin) Professional training instruments&apparatus 0 21st century