Patient Safety in Surgery PDF

Disclaimer Lecture source : Schwartz's Principles of Surgery, 11th Edition (2019) Pages 397 to 427 Power point slides only serves...

Disclaimer Lecture source : Schwartz's Principles of Surgery, 11th Edition (2019) Pages 397 to 427 Power point slides only serves as a guide in presenting chapter 12 of Schwartz's Principles of Surgery, 11th Edition Students are required to read the entire chapter 12 of Schwartz's Principles of Surgery, 11th Edition 31 Topic Outline (31) Background (2) I. Background (2) Mistakes inherent to human II. Science of Patient Safety (1) nature? III. Creating Culture of Safety (2) IV. Teamwork and Communication (0.5) Preventable? V. Communication Tools (1.5) What are these mistakes? VI. Comprehensive Unit-Based Safety Program (1) Evidenced-based medicine VII. Measuring Quality in Surgery (4) + wisdom = SCIENCE of VIII. “Never Events” in Surgery (3) PATIENT SAFETY IX. Transparency in Healthcare (1) X. Risk Management (2) XI. Complications (13) Background (2) :MEDICAL CARE GONE WRONG Overtreatment ( endemic ) Medical error : 3rd leading cause of death US Unintended act ( omission or commission ) or one that does not achieve its intended outcome Error of execution Error of planning Deviation Level? Avoidable? Morbidity vs mortality? Background (2) :MEDICAL CARE GONE Background (2) : UNNECESSARY MEDICAL WRONG CARE Strategies: Contribute to excess spending Make errors less frequent TYPES: Make errors more visible when they occur 22% prescription medications Have remedies at hand when errors affect a patient 25% medical tests 11% procedures BACK BACK Science of Patient Safety (1) : High Reliability Science of Patient Safety (1) : The Conceptual Organizations Model Humans who operate and manage complex systems are Donabedian model identifies 3 types of improvement themselves not sufficiently complex to sense and anticipate the Changes to organizational structure problems generated by the system Changes in organizational process Concept of normal accident theory Changes in outcomes “Best People can make the Worst Errors as a result of latent How care is organized plus process influences patient outcomes conditions.” Structure-process-outcome model High reliability organizations traits? Culture ? Creating Culture of Safety (2) Culture to Organization (Personality=Individual) Traditional surgical cultures? In the OR? In the ICU? BACK BACK Creating Culture of Safety (2) : Assessing an Teamwork and Communication (0.5) Organization’s Safety Culture Safety Attitudes Questionnaire (SAQ) Communication breakdown : 1. Teamwork climate over 60% of sentinel events 2. Safety climate OR : on of the most complex work 3. Job satisfaction environments in healthcare 4. Perception of management Traditional surgical hierarchy 5. Stress recognition 6. Working conditions Surgical sponge and instrument counts Surgeon and pathologist communication BACK BACK Teamwork and Communication (0.5) Communication Tools (1.5) Surgeons : anticipate Tools to identify and mitigate hazards their needs and follow To foster a culture of open communication and speaking up if a instructions team member senses a safety concern Nurses : Input is respected 1. Operating Room Briefings ( A Surgical Checklist) 2. Operating Room Debriefing 3. Sign outs BACK BACK Operating Room Briefings Operating Room Debriefing ( A Surgical Checklist) Postprocedural Reflections on causes of errors Learning opportunities Verification of the sponge, needle, and instrument counts Confirmation of correct labeling of surgical specimen Sign outs Comprehensive Unit-Based Safety Program (1) Verbal or written Care provided to patients is becoming more fragmented communication of patient Fragmentation = difficult communication information to familiarize oncoming physicians about Common sense solutions patients who will be under Unit-based meetings held regularly their care Changing provider Adequate endorsement BACK BACK BACK BACK Measuring Quality in Surgery (4) Measuring Quality in Surgery (4) Practice Pattern Measures The Surgical Care Improvement Doctor-defined Project (SCIP) Specialty-specific Reduce surgical complications “Average number of tissue blocks a skin cancer Identified three areas (Mohs) surgeon will use to surgically remove a SSI skin cancer” Venous thromboembolism Adverse cardiac events Agency for Healthcare Research and Quality (AHRQ) PSI ( Patient Safety Indicators) Measuring Quality in Surgery (4) Measuring Quality in Surgery (4) National Surgical Quality National Quality Forum (NQF) Improvement Program (NSQIP) Set national priorities and goals for Hospitals comparing post- performance improvement operative events Developed a list of Serious Reportable Uses risk-adjusted ratio of the Events observed to expected outcome ( 30 “Never Events” day morbidity and mortality) The Leapfrog Group Helped in standardizing EBM in US BACK BACK “Never Events” in Surgery (3) “Never Events” in Surgery (3) Clearly identifiable, preventable Surgical Counts with serious consequences Bypassing the surgical count Retained surgical items Falsely correct count Increased risk during emergency Known incorrect count surgery Most common : sponge Wrong-Site Surgery X-ray ? Orthopedic, General Surgery, Neurosurgery, Urology Preoperative “TIME-OUT” or “pause for the cause” BACK BACK Transparency in Healthcare (1) Risk Management (2) Data on patient safety and harm not available ½ to 2/3 hospital-wide adverse events = SURGICAL CARE Practice outdated medicine Occur in the OR and Technical in nature % Mortality % Morbidity Technical Error < Surgeon’s Communication Skills The Importance of Communication in Managing Risk Relating to patient “negative” manner → Litigious feeling Relating to patient “positive” manner → no Litigious feeling BACK Rapport is the most important factor BACK  Complications (13) Robotic Surgery(0.5) Complications in Minor Procedures(2.5) Organ System Complications (6) Wound, Drains, and Infection (3) Nutritional and Metabolic Support Complications(1) Problems with Thermoregulation(1) BACK BACK Robotic Surgery(0.5) Complications in Minor Procedures(2.5) Risk inherent in the new Central Venous Access Catheters technology Internal jugular vein vs Subclavian vein Delay / failure achieving expertise Complications: Pneumothorax : proper positioning / correct technique Device failures ( Arrhythmias : guidewire placement Electrocautery and Arterial Puncture instrument malfunction) Lost Guidewire Air Embolus : left lateral decubitus Trendelenburg: Xray for DX Pulmonary Artery Rupture Central Venous Line Infection Complications in Minor Procedures(2.5) Complications in Minor Procedures(2.5) Arterial Lines Endoscopy ABGs and Hemodynamic monitoring Risk : Perforation Radial, femoral, brachial, axillary, dorsalis pedis Abdomninal xray (upright) Complications: Open / Laparoscopic Thrombosis Bleeding Hematoma Bronchoscopy Infection Risk : Bronchial plug, hypoxemia, pneumothorax, lobar collapse, and Arterial spasm bleeding CTT Complications in Minor Procedures(2.5) Complications in Minor Procedures(2.5) Tracheostomy Angiography Early 14 days Intramural dissection → depends where? TIAF ( tracheoinnominate artery fistula) : 80% mortality rate Carotid artery : stroke SMA : mesenteric ischemia Peripheral limb artery : Blue toe syndrome Percutaneous Endogastrostomy Bleeding Misplaced PEG : intra-abdominal sepsis Renal Complications Tube thoracostomy For pneumothorax, hemothorax, pleural effusion, empyema Pain control, lung/diaphragm laceration, intraperitoneal, bleeding Complications in Minor Procedures(2.5) Organ System Complications (6) Biopsies Neurologic System Lymph node biopsy Motor or sensory deficits Bleeding, infection, lymph leakage, seromas Mental status changes Proper surgical hemostasis, skin preparation Peripheral motor and sensory 2 to neuropraxia (1-3 months) Single preop antibiotic 30-60mins before incision Direct injury to nerve : How control bleeding? Superficial parotidectomy Infection? Carotid endarterectomy Thyroidectomy Seromas? Prostatectomy Inguinal herniorrhaphy Mastectomy Organ System Complications (6) Organ System Complications (6) Eyes, Ears, and Nose Thyroid and Parathyroid Glands Corneal Abrasion during anesthesia Hypocalcemia Persistent epistaxis : NGT ECG ( shortened P-R interval) Ototoxicity due to aminoglycoside administration Chvostek’s & Trousseau’s sign Calcium gluconate infusion Vascular Problems of the Neck RLN / Superior laryngeal nerve injury Expanding neck hematoma Direct Laryngoscopy Intraoperative hypotension : manipulation of carotid bifurcation Organ System Complications (6) Organ System Complications (6) Respiratory System Cardiac System Pneumothorax Arrhythmias -> MC is Atrial fibrillation Tension Pneumothorax Acute myocardial infarction (AMI) Pulmonary Atelectasis → pneumonia Increase FRC 700mL by sitting >45 degrees Gastrointestinal System Early ambulation Esophageal Surgeries : Transthoracic Ivor-Lewis vs Transhiatal? Pain control Post-operative ileus : dysfunction of neural reflex axis of the intestine Bronchial Plug / Lobar Collapse : inadequate pulmonary toilet Metoclopramide : stomach duodenum Aspiration→ Pneumonitis : 70-80% mortality Erythromycin : stomach / bowel Pneumonia : 2nd MC infection in ventilated patients Alvimopan ( newer agent of opioid receptor antagonist) Neostigmine : refractory pan-ileus patients ( Ogilvie’s syndrome) Organ System Complications (6) Organ System Complications (6) Gastrointestinal System Hepatobiliary-Pancreatic System Small Bowel Obstruction : Technical errors hyaluronidase ? Laparoscopic cholecystectomy Fistula Bile duct injury FRIENDS ( Foreign body, Radiation, Ischemia/Inflammation/Infection, Epithelization of a tract, Neoplasia, Distal Renal System Obstruction, and Steroid use) Renal failure : pre-, intrinsic, post- GI bleeding Postrenal : MC misplaced/clogged IFC Prerenal : ATN Acute tubular necrosis Organ System Complications (6) Organ System Complications (6) Musculoskeletal System Hematologic System Compartment Syndrome : pain with passive motion ( hallmark ) When to transfuse? Hgb7mg/dL Hct 21% Direct pressure measurement >20 to 25 mmHg Symptomatic anemia, significant cardiac disease Four-compartment Faciotomy Transfusion Reaction Decubitus ulcers ON warfarin : FFP (200 to 250 mL of plasma) Significant after 2 hours of sustained pressure Thrombocytopenia 25 to 30 mmHg Tx: open incision Wound, Drains, and Infection (3) Wound, Drains, and Infection (3) Wound (surgical site) Infection Drain Management Preop antibiotics > 24 hrs? Open drains : for large contaminated wounds , prevent premature closure Irrigation of operative field: saline solution vs antibiotic of an abscess cavity Wound colonization vs wound infection? Closed suction drainage systems : 70 – 170 mmHg Antibiotics 24 to 48 hrs after drain placement Drain Management : indications 1. Collapse surgical dead space Urinary Catheters 2. Provide focused drainage of an abscess Insert full length, urine flow, balloon inflation 3. Proved early warning notice of a surgical leak ( sentinel drain ) Enlarged prostate 4. Control an established fistula leak UTI : MC nosocomial infection Wound, Drains, and Infection (3) Wound, Drains, and Infection (3) Empyema Necrotizing Fasciitis Infection of pleural space Fulminant soft tissue infections Chest xray, aspiration CS, CTT Surgical emergency antibiotics Systemic Inflammatory Abdominal Abscesses Response Syndrome, Sepsis, CT scan and Multiple-Organ Dysfunction Drainage, CS Syndrome antibiotics Nutritional and Metabolic Support Nutritional and Metabolic Support Complications(1) Complications(1) Nutrition-Related Complications Metabolism-Related Complications Use enteral feeding whenever possible “Stress Dose Steroids” : replicate physiologic steroid replacement NGT : Aspiration, TPN : pneumothorax 20mg/day prednisone Refeeding syndrome Adrenal Insufficiency Glycemic Control Thyroid hormone abnormalities Sick-euthyroid syndrome ( critical care setting ) Every 1-2 hours blood glucose determination Problems with Thermoregulation(1) Problems with Thermoregulation(1) Hypothermia Hyperthermia Core temperature < 35°C Core temperature >38.6°C Mild 35-32 Environmental ( summer heat ) Moderate 32-28 Iatrogenic (heat lamps, Medications) Severe