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Principles of Surgical Patient Safety

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Textbook of Polytrauma Management

Abstract

Patient safety in surgery has historically suffered from a lack of physician-driven initiatives aimed at recognizing, preventing, and mitigating medical errors and surgical complications. In spite of a multiplicity of global patient safety initiatives, the pertinent surgical safety protocols fall short of protecting patients from suffering unintended harm and adverse outcomes. A surgeon-driven leadership with unwavering advocacy for patient safety checklists and non-technical skills, including effective communication and individual accountability, is needed to build and sustain an encompassing culture of patient safety in analogy to the “high reliability” paradigm from other high-risk industries.

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References

  1. Stahel PF, Mauffrey C. Patient safety in surgery. London, UK: Springer; 2014.

    Book  Google Scholar 

  2. Kim FJ, da Silva RD, Gustafson D, Nogueira L, Harlin T, Paul DL. Current issues in patient safety in surgery: a review. Patient Saf Surg. 2015;9:26.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Stahel PF, Mauffrey C, Butler N. Current challenges and future perspectives for patient safety in surgery. Patient Saf Surg. 2014;8:9.

    Article  PubMed  PubMed Central  Google Scholar 

  4. American College of Surgeons Committee on Trauma. Advanced trauma life support (ATLS) student course manual. 10th ed. Chicago, IL: ACS-COT; 2018.

    Google Scholar 

  5. Sierink JC, Saltzherr TP, Beenen LF, et al. A multicenter, randomized controlled trial of immediate total-body CT scanning in trauma patients (REACT-2). BMC Emerg Med. 2012;12:4.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Wachter RM. Understanding patient safety. 2nd ed. New York: McGraw-Hill; 2012.

    Google Scholar 

  7. Oster CA, Braaten JS. High reliability organizations - a healthcare handbook for patient safety & quality. Indianapolis, IN: Sigma Theta Tau International; 2016.

    Google Scholar 

  8. Stahel PF, VanderHeiden TF, Kim FJ. Why do surgeons continue to perform unnecessary surgery? Patient Saf Surg. 2017;11:1.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Janssen SJ, Teunis T, Guitton T, Ring D. Do surgeons treat their patients like they would treat themselves? Clin Orthop Relat Res. 2015;473:3564–72.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Lisanne Johanna HS, Wilkens SC, Ring D, Guitton TG, Chen N. Variation in nonsurgical treatment recommendations for common upper extremity conditions. J Am Acad Orthop Surg. 2019;27:575–80.

    Article  PubMed  Google Scholar 

  11. Stahel PF, Wang P, Hutfless S, McCarty E, Mehler PS, Osgood GM, Makary MA. Surgeon practice patterns of arthroscopic partial meniscectomy for degenerative disease in the United States: a measure of low-value care. JAMA Surg. 2018;153:494–6.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Cohen TN, Gewertz BL, Shouhed D. A human factors approach to surgical patient safety. Surg Clin North Am. 2021;101:1–13.

    Article  PubMed  Google Scholar 

  13. Makary MA, Daniel M. Medical error: the third leading cause of death in the US. BMJ. 2016;353:i2139.

    Article  PubMed  Google Scholar 

  14. James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013;9:122–8.

    Article  PubMed  Google Scholar 

  15. Stahel PF. Surgical patient safety: a case-based approach. New York: McGraw-Hill; 2018.

    Google Scholar 

  16. Xu T, Makary MA, Al Kazzi E, Zhou M, Pawlik TM, Hutfless SM. Surgeon-level variation in postoperative complications. J Gastrointest Surg. 2016;20:1393–9.

    Article  PubMed  Google Scholar 

  17. Brooke BS, Dominici F, Pronovost PJ, Makary MA, Schneider E, Pawlik TM. Variations in surgical outcomes associated with hospital compliance with safety practices. Surgery. 2012;151:651–9.

    Article  PubMed  Google Scholar 

  18. Erestam S, Haglind E, Bock D, Andersson AE, Angenete E. Changes in safety climate and teamwork in the operating room after implementation of a revised WHO checklist: a prospective interventional study. Patient Saf Surg. 2017;11:4.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Bonvicini KA, Burney DW. Communication skills for surgeons. In: Stahel PF, editor. Surgical patient safety: a case-based approach. New York: McGraw-Hill; 2018. p. 3–14.

    Google Scholar 

  20. Greenberg CC, Regenbogen SE, Studdert DM, et al. Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg. 2007;204:533–40.

    Article  PubMed  Google Scholar 

  21. Stahel PF, Butler N. Effective communication: tips and tricks. In: Stahel PF, Mauffrey C, editors. Patient safety in surgery. London, UK: Springer; 2014. p. 115–21.

    Google Scholar 

  22. Stahel PF, Douglas IS, VanderHeiden TF, Weckbach S. The history of risk: a review. World J Emerg Surg. 2017;12:15.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Stahel PF. Learning from aviation safety: a call for formal “readbacks” in surgery. Patient Saf Surg. 2008;2:21.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Anderson DZ. Correcting readbacks. Aviation Saf. 2008;28:3.

    Google Scholar 

  25. Hoover EL. Patient safety and surgeons: why the resistance? Arch Surg. 2007;142:1127–8.

    Article  PubMed  Google Scholar 

  26. Bonds RL. SBAR tool implementation to advance communication, teamwork, and the perception of patient safety culture. Creat Nurs. 2018;24:116–23.

    Article  PubMed  Google Scholar 

  27. Biffl WL, Gallagher AW, Pieracci FM, Berumen C. Suboptimal compliance with surgical safety checklists in Colorado: a prospective observational study reveals differences between surgical specialties. Patient Saf Surg. 2015;9:5.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Peceny P, Biffl WL. Surgical safety checklists - pitfalls and pearls. In: Stahel PF, Mauffrey C, editors. Patient safety in surgery. London, UK: Springer; 2014. p. 21–30.

    Google Scholar 

  29. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360:491–9.

    Article  CAS  PubMed  Google Scholar 

  30. Weiser TG, Haynes AB, Dziekan G, et al. Effect of a 19-item surgical safety checklist during urgent operations in a global patient population. Ann Surg. 2010;251:976–80.

    Article  PubMed  Google Scholar 

  31. Gawande A. The checklist manifesto: how to get things right. New York: Picador; 2010.

    Google Scholar 

  32. Stahel PF, Sabel AL, Victoroff MS, et al. Wrong-site and wrong-patient procedures in the universal protocol era: analysis of a prospective database of physician self-reported occurrences. Arch Surg. 2010;145:978–84.

    Article  PubMed  Google Scholar 

  33. Lembitz A, Clarke TJ. Clarifying “never events” and introducing “always events”. Patient Saf Surg. 2009;3:26.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Makary MA, Mukherjee A, Sexton JB, et al. Operating room briefings and wrong-site surgery. J Am Coll Surg. 2007;204:236–43.

    Article  PubMed  Google Scholar 

  35. Stahel PF, Mehler PS, Clarke TJ, Varnell J. The 5th anniversary of the “Universal Protocol”: pitfalls and pearls revisited. Patient Saf Surg. 2009;3:14.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Clarke TJ. Surgeons, sign your site! Patient Saf Surg. 2017;11:8.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Stahel PF, Mehler PS, Clarke TJ. Evidence-based safe surgical practices as adjuncts to the universal protocol. Arch Surg. 2011;146:489–90.

    Article  Google Scholar 

  38. Stahel PF. The Universal Protocol: pitfalls and pearls. In: Stahel PF, Mauffrey C, editors. Patient safety in surgery. London, UK: Springer; 2014. p. 175–84.

    Google Scholar 

  39. Fridrich A, Imhof A, Schwappach DLB. How much and what local adaptation is acceptable? A comparison of 24 surgical safety checklists in Switzerland. J Patient Saf. 2021;17(3):217–22.

    Article  PubMed  Google Scholar 

  40. Stahel PF. The tenth year of the “Universal Protocol”: are our patients safer today? Bone Joint. 2014;360(3):7–10.

    Google Scholar 

  41. Di Saverio S, Tugnoli G, Catena F, Birindelli A, Coniglio C, Gordini G. Surgeon accountability for patient safety in the Acute Care Surgery paradigm: a critical appraisal and need of having a focused knowledge of the patient and a specific subspecialty experience. Patient Saf Surg. 2015;9:38.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Fan CJ, Pawlik TM, Daniels T, et al. Association of safety culture with surgical site infection outcomes. J Am Coll Surg. 2016;222:122–8.

    Article  PubMed  Google Scholar 

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Stahel, P.F., Stahel, V.P. (2022). Principles of Surgical Patient Safety. In: Pape, HC., Borrelli Jr., J., Moore, E.E., Pfeifer, R., Stahel, P.F. (eds) Textbook of Polytrauma Management . Springer, Cham. https://doi.org/10.1007/978-3-030-95906-7_44

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  • DOI: https://doi.org/10.1007/978-3-030-95906-7_44

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