The latest ECRI and the Institute for Safe Medication Practices PSO Deep Dive explores one of the areas that accounts for a large portion of healthcare volume: surgical care.
Annually, surgery accounts for 7 million inpatient hospital stays and 36 million procedures in the outpatient setting. Although surgical safety has been the subject of guidelines, patient safety and quality improvement projects, and attention in the literature, adverse events continue to occur with relative frequency, putting patients at risk.
Based on an analysis of surgical data received through the Patient Safety Organization, plus detailed research and expert evaluation, this Deep Dive identifies and provides actionable recommendations and tools on six key risk categories of adverse event reports related to operative procedures:
- patient and OR readiness
- retained surgical instruments
- equipment failures
- wrong surgery.
There are common themes echoed through each of the six event types examined in this Deep Dive. These include the following:
- Communication problems are an underlying issue. Problems with communication—whether between the scheduler and the OR team, between clinical staff and the patient, or among the OR team—can lead to adverse events or near misses.
- Organisations should promote a team approach. Taking a team approach to surgical procedures can help avoid many of the adverse events reported in this Deep Dive. Such an approach is an element of a culture of safety and should be emphasised through team-building exercises.
- Organisations should focus on addressing preventable events. Some events are not preventable, meaning that no matter how well the team prepares, the event would likely have happened anyway. For example, the patient could have an allergic reaction resulting from an unknown anesthesia allergy, or a rare but known risk of surgery occurring. Focusing on preventable events can help focus the surgical team’s attention, however, thereby reducing the risk of unpreventable events as well.
- Quality improvement should be emphasized to reduce risk. Clinical staff should apply a quality improvement mentality to any problems that emerge, and focus on actions that can be taken to prevent such problems in the future.