LITERATURE REVIEW: SURGICAL CHECKLIST EFFECTIVE IN PATIENT SAFETY.

By: SEHER ANWAR ALI MARI

SUBMITTED TO THE FACULTY OF SURGICAL TECHNOLOGY 2011- 4th PROFESSIONAL YEAR. DOW INSTITUTE OF MEDICAL TECHNOLOGY (DIMT) KARACHI PAKISTAN.

SUBJECT CO-ORDINATOR: Dr. MASROOR AFRIDI.

Table of Contents Abstract.3 Objectives..4 Introduction..5 Methodology.6 Results6 Discussion..7 Conclusion10 References11

Abstract
Background
Surgical team safety is a serious epidemic that increasing world wide, the purpose of this survey is to Access the Quality of improvement in health care system. The surgical team safety combines challenges and rewards of medicine and science to improve the quality of patient care. Surgical personnel are sincere with their profession and do the best to save patients life even at cost of putting self in stake plus they play active role to save victims lives. Pakistan is now on a track of developing countries and we notice up trends in survival in health care system with availability of technical and human resources .Our goal is to ensure unexpected complications to weed out problems and meet the demands of modern worlds thereby save unnecessary loss of life and sophisticated health care system in this country. Our challenge is to improve the safety of surgical team and patient care Checklist usability and contribution to safer care in civil hospital Karachi. Surgical safety checklist designed to improve team communication and consistency of care to reduce complications and risk factors associated with surgery. Our aim is to core a set of safety standards that can be applied for quality improvement in hospital management. In 2008, the World Health Organization (WHO) published guidelines identifying multiple recommended practices to ensure the safety of surgical patients worldwide is signified to reduce the rates of death and major complications after surgery .(1),The checklists had improved care and prevent surgical infections Surgery has four major risk factors: infection, bleeding, anesthesia , and unexpected complications. The best way to resolve the unexpected is through team communication. (2) Thus, surgical care and its attendant complications represent a substantial burden of disease worthy of attention from the public health community worldwide. (3)The incredible potential improves patient care and save lives of more than 230 million operations performed every year. Routine briefing periods within the operating theatre schedule helps to reduce risks to patients, enhance teamwork and improve staff morale. Human error which are varied from incorrect treatment or procedure to misplaced patient notes which may led patient harm or death. Preventable errors there are many forms of preventable error(4). It is therefore essential hierarchy and manual tasks are being undertaken. In stressful situations those operating may develop visual impairment in an attempt to try and complete a task. This may cause problems when an alternative technique, calling for help or taking a time out is more appropriate. The use of a system of safety briefings using checklists within the operating theatre has been shown to reduce preventable errors and increase morale and satisfaction within theatre teams. By making the time to use these procedures, consultant surgeons and anesthetists may be in a position to alter current practice and change the culture so that the operating theatre becomes an even safer place for our patients. The pre-operative briefings and time-outs to enhance patients safety and reduce preventable errors(5-7).

Objectives
Provide maximum possible services focus on surgical team safety and checklist has been addressed by CHK (Civil hospital Karachi) .To update the knowledge surgical team safety and guideline has been established for benefits of health care workers and patients and to provide better service to our people. My Vision is to fully aware of upcoming medical research and update knowledge.

Introduction
Our goal is Surgical Team safety and briefing. Being our challenge for us to improve the safety of surgical team and patient care in civil hospital Karachi by defining a core set of safety standards that can be applied in hospital mangement.Creating .The literature review safety practice measurement of health care systems for quality improvement, as well as surgical personnel (the surgeon,anaesthetist, theatre nurses, operating department assistants) to have time together and with other teams and patient safety .The incredible potential improve patient care and save lives of more than 230 million operations performed every year. Routine briefing periods within the operating theatre schedule helps to reduce risks to patients, enhance teamwork and improve staff morale. Human error which are varied from incorrect treatment or procedure to misplaced patient notes which may led patient harm or death. Preventable errors there are many forms of preventable error. These can be errors of omission such as non-administration of antibiotics or thromboembolic prophylaxis whilst these may appear minor mistakes, they can have life-threatening consequences for patients. Blocked anesthetic tubing or broken equipment that has not been noticed may also harm patients, which results in tragic deaths (8). Incorrect documentation of patients which may delay the onset of surgeries and also effect rest of intervention(9). The most obvious avoidable error. Human error for example viewing CT scans in the incorrect alignment or failure to read the patients notes in detail. It is therefore essential hierarchy and manual tasks are being undertaken. In stressful situations those operating may develop visual impairment in an attempt to try and complete a task. This may cause problems when an alternative technique, calling for help or taking a time out is more appropriate. The use of a system of safety briefings using checklists within the operating theatre has been shown to reduce preventable errors and increase morale and satisfaction within theatre teams(10). By making the time to use these procedures, consultant surgeons and anesthetists may be in a position to alter current practice and change the culture so that the operating theatre becomes an even safer place for our patients. The pre-operative briefings and time-outs to enhance patient safety and reduce preventable error.

Methodology
I independently searched review articles all based on surgical team safety and checklist to identify incorporation of safety checks into debriefings can form the basis for patient safety to preventable error. I investigate different sites for leading moral support in patient care in various interventions, to minimize the complication error to reduce morbidity and mortality.

Results
The WHO checklist and associate for approach safe reliable care even is effective tools to improve all aspects of patient care and safety .The WHO Surgical Safety Checklist develops to set of surgical safety and standards in health care settings. WHO checklist could reduce deaths and disabilities by millions although introducing these checklists to help surgical teams do their best work to save lives. Unfortunately in one site the goal of checklist could not be achieve after the checklist was implemented, either because of surgical-site infection and unplanned reoperation can lead to cause decline. Therefore improvement was noticed in quality of health care system and in surgical outcomes after implementation of checklist. Checklist implementation encouraged the administration of antibiotics in the operating room rather than in the preoperative wards, where delays are frequent.

Discussion
A systematic literature review was made to examine the effectiveness of a surgical checklist on complications and mortality, and clinically measurable benefits were observed. The cost effects of the checklist were not estimated(11). However, use of the checklist presents a simple intervention with costs arising only from a few minutes of work input per surgical operation. The price of the extra time in the operating room can be compared, for example, against the costs of treating complications. As the data on effectiveness are based on only one high-class comparative observational study, the evidence assessed by the GRADE method is of level C (scanty)(12). The high quality of that study increases the credibility of the results, as does the fact that effectiveness was largely similar in hospitals studied in various countries. It is unlikely that the effectiveness of the checklist would even later be assessed by using randomized trial setup, but further data and evidence may accumulate from comparative observational setups(13). Research on how the checklist affects the work process in the operating room would also be needed. The checklist concentrates on deviations in the therapeutic process that have been found to be problematic, and on critical stages in the process. Good experiences have previously been obtained of systematic improvement of the safety of anesthesia. Thirty years ago, the risk of fatal complications arising from anesthesia for a healthy person undergoing general anesthesia was estimated at 1:5,000 (14). In an extensive review carried out in Australia in the Early 2000s, anesthesia mortality was estimated at 1:56,000 (15). In addition to more systematic use and further Development of the anesthesiological procedure, extensive use of pulse oximetry during surgery is considered to be one of the factors behind reduced mortality (16).On this basis of research results, other items on the checklist have also been considered crucial for safety. Checking the labeling of specimens, for example, is based on results showing that one half of laboratory errors are due to faulty labeling (17) and that one in 18 labeling errors leads to an adverse event (18). The checklist items are strongly recommended in WHO Safe Surgery Saves Lives guidelines (19).There are extensive recorded data available on the numbers of elective, emergency and day-case surgical operations in Finland. However, data on surgical mortality within 30 days of operation or data on complications have not been collected systematically. It was also surprising to find that there were no data on operating rooms in use in Finland. Data on individual patient groups are available, for instance, from the Perfect project, where the surgical indications included balloon angioplasty and bypass operations of coronary arteries, hip fractures, and hip and knee replacement surgery(20,21).The Finnish Patient Safety Strategy 2009-2013 by the Ministry of Social Affairs and Health emphasizes that clinical leaders must visibly bear the responsibility for promoting.Patient safety and that they cannot delegate this responsibility. This involves the assessment of all including economic decisions also from the point of view of patient safety. Management should facilitate and ensure working conditions that make safe treatment possible in the organization. Quality and risk management must also be considered (22). According to recently published studies (23,24), Hospitals striving in a goal-oriented manner to provide high-quality treatment can prevent as many as one half of all surgical complications. Further improvement of good results usually requires a high input in relation to the benefits achieved, but the checklist is a cheap tool and

easy to use. Adverse events should preferably be reported to the HILMO register. This could improve quality within the unit and could provide information at the national level .T he World Health Organization Surgical Safety Checklist, the most effective checklists are customized to fit local practice. Checklists should be created and updated by the teams that will actually use them. The best checklists function as standardized communication tools to promote information exchange and team cohesion and include the opportunity for the surgeon to conduct a quick team briefing. (24)Customized, site-specific pre procedure checklist briefings should cover the patient status, team members roles, the teams plans, and any potential pitfalls. Surgeons can encourage stop the line communication by concluding the briefing with something like, If you see, suspect, or feel that something is not right, I expect you to speak up. This type of thorough briefing promotes verbal communication and actively engages each team member to report his or her plan, concerns, and questions, behavior that would have broken the error chain causing the wrong surgery. (25)These behaviors are critically important as the lack of team vigilance and cross checking contributes to more than half of the adverse events in the OR setting. Dr. Smith, like many physicians, was probably concerned that using a checklist would take too much time. The evidence doesnt confirm this concern. As surgeons gain experience in using a checklist, an effective briefing and checklist can be done in a minute or less, with zero delays in start times. Team Resource Management Effective Team Resource Management refers to a teams ability to identify and use all available resources, to manage their workload, stress and fatigue and to communicate effectively to ensure team synergy and situational awareness is maintained throughout the entire procedure. Checklists and briefings are important resources that support the structure of a team, and guide communication throughout the procedure. Effective Team Resource Management is essential in the formation and preservation of surgical teams. Introductions are an extremely important component of Team Resource Management. Leadership is established and the tone is set for the open two way communication that is so vital in the operating room. A surgical team as a whole is greater than the sum of its parts.Multi-professional teamwork is an essential part of any surgical operation. It would not be possible for a surgeon to operate without the work and cooperation of other professionals. Teamwork is recognized as being vital in many settings. An analysis of the US National Basketball Association in 2001 showed a stronger correlation between team assist totals with win-loss record than individual assist totals for the five players receiving the most playing time [26]; in other words, team performance was a more important factor than individual performance in a winning team. Successful teams also feature in nature, whether it is dolphins herding fish [27] or a herd of buffalo thwarting a pride of lions in their attempt to take a calf [28]. Comparisons between healthcare and the aviation industry are common [29]. Aviation has a track record of safety despite complex human-human and humanmachine interactions and reliance on complex systems and technology. Pilots and cabin crew introduce themselves to each other and have a briefing before every flight using a comprehensive set of checklists to ensure the safety of the plane and its passengers. Safety questions are asked of the crew, and potential problems are discussed. This fosters an atmosphere of mutual respect and trust whilst promoting team building. In healthcare, we have some similar systems in place. For example, consent forms and operation site marking can be compared to flight tickets, and our patients are checked-in within the anesthetic room or operating theatre, but our mechanisms of ensuring this happens reliably are less robust. Patients would be surprised to hear that they can be already anaesthetized and covered in drapes before the operating surgeon comes into the

theatre to start operating. The surgeon can then start operating with individuals he or she is meeting for the first time. The surgeon may be relying on other members of the team to ensure that the correct patient is having the correct operation and that correct instruments are available (30).

Preventable errors There are many forms of preventable error. These can be errors of omission such as nonadministration of antibiotics or thromboembolic prophylaxis; whilst these may appear minor mistakes, they can have life-threatening consequences for patients. Blocked anesthetic tubing or broken equipment that has not been noticed may also harm patients, and has even resulted in tragic deaths [31]. Incorrect documentation (for example, of a patients ward) may delay the onset of surgery and have a knock-on effect on the running of the rest of a list. Possibly the most obvious avoidable error is that of wrong-site surgery. Despite massive publicity and hospital procedures to prevent these errors, they have still occurred. This illustrates how despite best intentions, human error (e.g., viewing CT scans in the incorrect alignment or failure to read the patients notes in detail) can still have devastating consequences. Even when individuals in the operating theatre have known an error was about to be made they have often not spoken out. It is therefore essential that there is a culture that allows any team member to express .The team will operate on the correct patient at the correct site. The team will use methods known to prevent harm from administration of anesthetics, while protecting the patient from pain. The team will recognize and effectively prepare for life-threatening loss of airway or respiratory function. The team will recognize and effectively prepare for risk of high blood loss. The team will avoid inducing an allergic or adverse drug reaction for which the patient is known to be at significant risk. Guidelines In an attempt to improve patient safety, and in particular address the potentially devastating consequences of wrong site surgery, recommendations on pre-operative patient identification, operation site marking and the use of time-out procedures were published in the US in 2003 as The Universal Protocol by the Joint Commission on Accreditation of Healthcare Organizations, a body charged with increasing patient safety [31]. In the UK, the National Patient Safety Agency (NPSA) also published guidelines on avoiding wrong site surgery and an accompanying checklist Performa in 2005 [32]. In June 2007, the Royal College of Surgeons of England publication Leadership and management of surgical teams (33) emphasized the role of the surgical team and the leadership role required of consultant surgeons. Its guidelines state Patient safety is at the centre of care provided by all clinicians and is enhanced by effective leadership and team working by all clinical staff. It is the consultant surgeon Responsibility to develop an effective team in a clinical setting through leadership and team building. Situational awareness is a key attribute for sound decision making for all staff members. This is achieved through properly structured briefing and de-briefing of all staff responsible for patient care. The Consultant surgeon has a moral obligation to ensure that this occurs, for the patients safety and the accountability of clinical staff(33).

Additional benefits Improved teamwork and communication among clinicians improves job satisfaction and reduces job stress and turnover(33). In the OR, preoperative briefings have been shown to increase team satisfaction. Additionally, surgical cases would proceed more efficiently as team briefings, using a script, reduce surgical flow disruptions. Teamwork training and checklist usage improve surgeon, staff, and institutional efficiency. The number of uneventful cases (cases that are booked correctly, start on time, have no unplanned delays, and finish on time) increase, and case length and turnaround times decrease, even when the surgeon is learning to perform a new procedure(35). Most importantly, patients benefit when healthcare workers participate in teamwork training and use checklists. Better teamwork performance among clinicians improves patient satisfaction. In addition, when surgical teams communicate and collaborate more effectively, patients benefit from lower hospital lengths of stay, greater gains in functional status, and reduced mortality and morbidity. By investing time and effort in improving his communication and teamwork skills, along with the disciplined use of scripted briefings and checklists, Dr. Smith could have error-proofed his practice, and predictably improved outcomes quality, as well as patient safety and satisfaction. But the greatest benefit of all A clear conscience, untainted by the bitter life long memory of a needless mistake.

Conclusion
Validated evidence-based initiatives need to be strongly emphasized and publicized to medical and paramedical staff for the benefit of patients and the healthcare systems. Awareness and understanding lead to improved outcomes. Safety and efficiency have a symbiotic relationship in high quality, patient-centered, medical care. The WHO's SSC checklist allows the same fundamental safety checks to be completed for any patient, every time. Using this uniform checklist can further reduce the mortality and morbidity of surgery.

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19 National Patient Safety Agency. Rapid Response Report 9: Avoiding wrong side burr holes/ craniotomy. www.npsa.nhs.uk 2008 20 Kohn LT, Corrigan J, Donaldson MS. To err is human: building a safer health system. Institute of Medicine (US). 2000 21 National Patient Safety Agency and the Royal College of Surgeons. Patient Safety Alert: correct site surgery. www.npsa.nhs.uk 2005 22 NPSA Correct site surgery guidelines and checklist; 2005 23 The leadership and management of surgical teams. RCSEng - Professional Standards and Regulation; 2007 24 WHO: Safe Surgery Saves Lives; 2008 25] Defontes J. Pre-operative Safety Briefing Project. The Permanente Journal 2004; 8:21-7 26 Wright M. KP Northwest Pre-operative Briefing Project. The Permanente Journal 2005; 9:35-9 27 Lingard L, Espin S, Rubin B et al. Getting teams to talk: development and pilot implementation of a checklist to promote multi-disciplinary communication in the OR. Qual. Saf. Health Care 2005; 14:340-46 28 Lingard, L, Regehr, G, Orser, B, et al. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg 2008; 143:12-7. 29 Hooper G, Darley D, Patton D, Perry A and Skelton R. Time-out. Avoiding wrong site surgeryan audit of six months experience. Journal of Bone and Joint Surgery - British Volume, Vol 88-B, Issue SUPP II, 30Haynes AB, Weiser TG, Berry WR, et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. NEJM 2009;360:491-9\] [31 http://www.npsa.nhs.uk/nrls/patient-safety-incident-data/quarterly-data-reports/ 32 www.npsa.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=19160 33 Christian CK, Gustafson ML, Roth EM, et al.. A prospective study of patient safety in the operating room. Surgery 2006; 139:159-73. 34 Melkin MJ. Relationship between team assists and win-loss record in the NBA. Percept Mot Skills 2001; 92:595-602 35 http://video.nationalgeographic.com/video/player/kids/animals-pets-kids/mammals-kids/dolphinfishing-kids.html

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