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SAFE SURGIES CHECKLIST A PATH TO PATIENT SAFETY

SAFE SURGIES CHECKLIST A PATH TO PATIENT SAFETY. Rola Hammoud, MD,DA,MHM. Safety in Healthcare. Amalberti, R. et. al. Ann Intern Med 2005;142:756-764 . Adverse events. Causes Rarely due to lack of knowledge of care givers 1. Lack of organisation ( time, resources )

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SAFE SURGIES CHECKLIST A PATH TO PATIENT SAFETY

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  1. SAFE SURGIES CHECKLISTA PATH TO PATIENT SAFETY Rola Hammoud, MD,DA,MHM

  2. Safety in Healthcare Amalberti, R. et. al. Ann Intern Med 2005;142:756-764

  3. Adverse events Causes Rarely due to lack of knowledge of care givers 1. Lack of organisation ( time, resources) 2. Lack of verification 3. Lack of coordination ( Human – Machine interface) 4. Lack of communication = Lack of SAFETY CULTURE

  4. Adverse EventsIndividual Factors • Limited memory capacity • Memory decreases with : - Fatigue • Stress • Hunger • Sickness • Cultural and language barriers • Hazardous attitudes

  5. Establish a Culture

  6. Strategies to improve Patient Safety Improve systems Leadership Standardization Technology Human factor engineering Improve communication: language standard , checklists, debriefings 3. Team Work 4. Other interventions: staffing et RH, training & education Learn from our errors : M&M, RCA, Incident reporting, medical record review Just Culture

  7. HOW to Standardize Checklists Protocols Clinical Guidelines Pathways

  8. CHECKLISTS

  9. Checklist An algorithmic listing of actions to be performed in a given clinical setting Goal : ensure that no step will be forgotten. Has a sound theoretical basis in principles of human factors engineering Play a major role in some of the most significant successes achieved in the patient safety movement.

  10. JCI Patient Safety Goals Patient Identification Improve Communication among caregivers Improve the safety of using medications Reduce the risk of healthcare associated infections Avoid Wrong patient-wrong site- Wrong surgery Reduce the risk of patient harm resulting from falls

  11. SAFE SURGERIES When a patient is wheeled in to an Operating Room, the single biggest worry before losing consciousness is ….. that the surgeon will mix him up with another patient, or perform a wrong surgery.. It's a reality. In many cases, mistakes happened

  12. SAFE SURGERIESIATROGENIC SURGICAL ERRORS Identification errors Site errors Retained sponges & instruments Surgical site Infections Unanticipated major bleedings Failure of equipments Anesthesiology mishaps & medication errors Burns due to cautery misuse Neuropathies due to bad positioning

  13. SAFE SURGERIESUNIVERSAL PROTOCOL • 1. Preoperative verification process • 2. Marking of the operative site • 3. “Time Out” immediately before starting the procedure.

  14. SAFE SURGERIESPreoperative verification process Verify the correct procedure, person and site: • 1. At the time surgery is scheduled. • 2. Upon admission to the hospital. • 3. On transfer of the responsibility of care between caregivers. • 4. with the patient involved, awake and aware.

  15. SAFE SURGERIESPreoperative verification checkilst • 1. Relevant documentation ( eg.H&P and consents) • 2. Relevant images properly labelled and displayed • 3. Any required implants and special equipments.

  16. SAFE SURGERIESOperative Site Marking • Purpose: To identify unambiguously the intended site of incision or insertion. • Process: For procedures involving right/left distinction, multiple structures (such as fingers and toes), or multiple levels (as in spinal procedures), the intended site must be marked such that the mark will be visible after the patient has been prepped and draped.

  17. SAFE SURGERIESTIME OUT JCI Universal Protocol calls for a "time out" immediately before starting a surgical procedure. Prior to draping the patient and prepping the site. During the time out, the surgical team verifies the procedure, site, side, and patient identification for accuracy

  18. WHO SurgicalSafety Checklist Improved interdisciplinary communication: Relaying the information in a loud voice Introducing each other to the rest of the team

  19. WHO SurgicalSafety Checklist Factorsfacilitating the use of the checklist Structured training Exemplaryimplementation by team leaders

  20. WHO SurgicalSafety Checklist Can be completed in about two minutes Improves safety and patient outcomes when adhered to in the operating room, according to an analysis of 20 studies.

  21. WHO SurgicalSafety Checklist Surgical outcome study indicated a decrease of 47% in perioperative mortality, from 56 deaths in 3733 cases (1.5%) to 32 deaths in 3955 cases (0.8%). A second study showed a decrease of 62%, from 31 deaths in 842 cases (3.7%) to 13 deaths in 908 cases (1.4%). These 2 studies also showed a more than a one third decrease in perioperative morbidity outcomes. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al: A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 360:491–499, 2009

  22. SurgicalSafetyChecklist Training surgical teams in communication and using a procedure checklist before, during, and after surgery may significantly decrease 30-day postoperative complications such as surgical site infections and bleeding requiring transfusions. study conducted at 2 Connecticut medical centers

  23. SurgicalSafetyChecklist

  24. SurgicalSafetyChecklist NSQIP : Reduction in adverse events Reduction of 30 days morbidity rates

  25. SurgicalSafetyChecklist This study demonstrates a considerable improvement in risk-adjusted 30-day postoperative morbidity. The implementation of team training and accountability measures, such as the comprehensive checklist, are inexpensive interventions that can contribute to cost savings in the expanding environment of pay for performance and increase patient satisfaction with the perioperative experience.

  26. OtherSurgicalSafetyChecklists SURPASS Neurosurgerychecklists QRS : Quality Rounds Checklists "Sign, Mark and X-ray" program

  27. Spine surgery wrong-level checklist developed by NASS*

  28. SAFE DELIVERIES

  29. WHO Estimations on deliveries More than 130 million births each year Nearly 287 000 result in the mother’s death, 1 million in an intrapartum related stillbirth, 3 million death during the neonatal period.

  30. WHO Estimations on deliveries The greatest burden of maternal and perinatal mortality is clustered around the time of birth, with the majority of deaths occurring within the first 24 hours after childbirth.

  31. WHO Safe Childbirth Checklist Program Established in consultation with General practitioners Obstetricians Anesthetists Nurses Midwives Patient safety Experts and patients around the world

  32. Surgical and DeliverySafetyChecklists Makes sure that a TEAM isadvocating for the PATIENT

  33. THANK YOU

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