Future Directions of Surgical Safety

Chapter

Abstract

Surgical care has evolved over the last century into a complex delivery system where errors in patient care occur throughout the entire perioperative period. Efforts to improve the quality of care and promote patient safety must include tools and conceptual frameworks from industries outside of health care. Systems engineering, establishing a culture of safety, and resilience engineering are systematic approaches to drive quality improvement, avoid errors, and minimize harm when errors do occur. These improvement strategies should be subjected to the same scientific rigor used in other areas of clinical research to determine which approaches are most effective. Physicians must embrace improvement science in order to drive and shape future quality and safety initiatives.

Keywords

Health care systems engineering Culture of safety Team training Checklists Team briefings High reliability organizations Resilience engineering Improvement science 

References

  1. 1.
    IOM. To err is human: building a safer health system. Washington, DC: National Academy Press; 2000.Google Scholar
  2. 2.
    IOM. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001.Google Scholar
  3. 3.
    NPS Foundation. Free from harm: accelerating patient safety improvement fifteen years after ‘To Err is Human’. Boston, MA: NPS Foundation; 2015.Google Scholar
  4. 4.
    Technology PsCoAoSa. Better health care and lower costs: accelerating improvement through systems engineering. Washington, DC: Technology PsCoAoSa; 2014.Google Scholar
  5. 5.
    James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013;9(3):122–8.CrossRefPubMedGoogle Scholar
  6. 6.
    Makary MA, Daniel M. Medical error—the third leading cause of death in the US. BMJ. 2016;353:I1239.Google Scholar
  7. 7.
    Services CfMM. National Health Expenditure Projections 2014–2024. 2016. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/proj2014.pdf. Accessed 28 Apr 2016.
  8. 8.
    Agha RA, Fowler AJ, Sevdalis N. The role of non-technical skills in surgery. Ann Med Surg (Lond). 2015;4(4):422–7.CrossRefGoogle Scholar
  9. 9.
    Stahel PF, Mauffrey C, Butler N. Current challenges and future perspectives for patient safety in surgery. Patient Saf Surg. 2014;8(1):9.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Cassin B, Barach P. Making sense of root cause analysis investigations of surgery-related adverse events. Surg Clin North Am. 2012;92(1):101–15. doi: 10.1016/j.suc.2011.12.008.CrossRefPubMedGoogle Scholar
  11. 11.
    Valdez RS, Ramly E, Brennen PF. Industrial and systems engineering and health care: critical areas of research—final report. Rockville, MD: Agency for Healthcare Research and Quality; 2010.Google Scholar
  12. 12.
    Cevasco M, Ashley SW. Quality measurement and improvement in general surgery. Perm J. 2011;15(4):48–53.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Pugel AE, Simianu VV, Flum DR, Patchen DE. Use of the surgical safety checklist to improve communication and reduce complications. J Infect Public Health. 2015;8(3):219–25.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Russ S, Rout S, Sevdalis N, Moorthy K, Darzi A, Vincent C. Do safety checklists improve teamwork and communication in the operating room? A systematic review. Ann Surg. 2013;258(6):856–71.CrossRefPubMedGoogle Scholar
  15. 15.
    Schraagen JM, Schouten A, Smit M, van der Beek D, Van de Ven J, Barach P. A prospective study of paediatric cardiac surgical microsystems: assessing the relationships between non-routine events, teamwork and patient outcomes. BMJ Qual Saf. 2011;20(7):599–603. doi: 10.1136/bmjqs.2010.048983.CrossRefPubMedGoogle Scholar
  16. 16.
    Berwick DM. Era 3 for medicine and health care. JAMA. 2016;315(13):1329–30.CrossRefPubMedGoogle Scholar
  17. 17.
    Johnson J, Barach P. Quality improvement methods to study and improve the process and outcomes of pediatric cardiac surgery. Progr Pediatr Cardiol. 2011;32:147–53.CrossRefGoogle Scholar
  18. 18.
    Phelps G, Barach P. Why the safety and quality movement has been slow to improve care? Int J Clin Pract. 2014;68(8):932–5.CrossRefPubMedGoogle Scholar
  19. 19.
    Berwick DM. Continuous improvement as an ideal in health care. N Engl J Med. 1989;320(1):53–6.CrossRefPubMedGoogle Scholar
  20. 20.
    Chassin MR, Loeb JM. The ongoing quality improvement journey: next stop, high reliability. Health Aff (Millwood). 2011;30(4):559–68.CrossRefGoogle Scholar
  21. 21.
    Donabedian A. Evaluating the quality of medical care. 1966. Milbank Q. 2005;83(4):691–729.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Bilimoria KY, Liu Y, Paruch JL, et al. Development and evaluation of the universal ACS NSQIP surgical risk calculator: a decision aid and informed consent tool for patients and surgeons. J Am Coll Surg. 2013;217(5):833–42. e831–3.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Birkmeyer JD, Dimick JB, Birkmeyer NJ. Measuring the quality of surgical care: structure, process, or outcomes? J Am Coll Surg. 2004;198(4):626–32.CrossRefPubMedGoogle Scholar
  24. 24.
    Birkmeyer JD, Finks JF, O’Reilly A, et al. Surgical skill and complication rates after bariatric surgery. N Engl J Med. 2013;369(15):1434–42.CrossRefPubMedGoogle Scholar
  25. 25.
    Grenda TR, Pradarelli JC, Dimick JB. Using surgical video to improve technique and skill. Ann Surg. 2016;264:32–3.CrossRefPubMedGoogle Scholar
  26. 26.
    The National Academies Press. Building a better deliver system. Washington, DC: The National Academies Press; 2005.Google Scholar
  27. 27.
    Best M, Neuhauser D. Walter A Shewhart, 1924, and the Hawthorne factory. Qual Saf Health Care. 2006;15(2):142–3.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Taylor MJ, McNicholas C, Nicolay C, Darzi A, Bell D, Reed JE. Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Qual Saf. 2014;23(4):290–8.CrossRefPubMedGoogle Scholar
  29. 29.
    Pronovost PJ, Ravitz AD, Stoll R, Kennedy S. Transforming patient safety: a sector-wide systems approach. Qatar: WISH Patient Safety Forum; 2015.Google Scholar
  30. 30.
    Services CfMM. Bundled Payments for Care Improvement (BPCI) initiative: general information. 2016. https://innovation.cms.gov/initiatives/bundled-payments/. Accessed 28 Apr 2016.
  31. 31.
    Azhar RA, Bochner B, Catto J, et al. Enhanced recovery after urological surgery: a contemporary systematic review of outcomes, key elements, and research needs. Eur Urol. 2016;70:176–87.CrossRefPubMedGoogle Scholar
  32. 32.
    Desebbe O, Lanz T, Kain Z, Cannesson M. The perioperative surgical home: an innovative, patient-centred and cost-effective perioperative care model. Anaesth Crit Care Pain Med. 2016;35(1):59–66.CrossRefPubMedGoogle Scholar
  33. 33.
    Kash BA, Zhang Y, Cline KM, Menser T, Miller TR. The perioperative surgical home (PSH): a comprehensive review of US and non-US studies shows predominantly positive quality and cost outcomes. Milbank Q. 2014;92(4):796–821.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Vetter TR, Jones KA. Perioperative surgical home: perspective II. Anesthesiol Clin. 2015;33(4):771–84.CrossRefPubMedGoogle Scholar
  35. 35.
    Commission J. Joint Commission Resources Quality and Safety Network: accreditation updates. 2016. http://www.jcrqsn.com/VA/AccreditationUpdates.html. Accessed 24 Apr 2016.
  36. 36.
    Network PS. Safety culture. https://psnet.ahrq.gov/primers/primer/5/safety-culture. Accessed 26 Apr 2016.
  37. 37.
    Bognar A, Barach P, Johnson J, Duncan R, Woods D, Holl J, Birnbach D, Bacha E. Errors and the burden of errors: attitudes, perceptions and the culture of safety in pediatric cardiac surgical teams. Ann Thorac Surg. 2008;4:1374–81.CrossRefGoogle Scholar
  38. 38.
    Macrae C. The problem with incident reporting. BMJ Qual Saf. 2016;25(2):71–5.CrossRefPubMedGoogle Scholar
  39. 39.
    Amalberti R, Auroy Y, Berwick DM, Barach P. Five system barriers to achieving ultra-safe health care. Ann Intern Med. 2005;142(9):756–64.CrossRefPubMedGoogle Scholar
  40. 40.
    Barach P, Phelps G. Clinical sensemaking: a systematic approach to reduce the impact of normalised deviance in the medical profession. J R Soc Med. 2013;106(10):387–90. doi: 10.1177/0141076813505045.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Mitchell I, Schuster A, Smith K, Pronovost P, Wu A. Patient safety incident reporting: a qualitative study of thoughts and perceptions of experts 15 years after ‘To Err is Human’. BMJ Qual Saf. 2016;25(2):92–9.CrossRefPubMedGoogle Scholar
  42. 42.
    Tsao K, Browne M. Culture of safety: a foundation for patient care. Semin Pediatr Surg. 2015;24(6):283–7.CrossRefPubMedGoogle Scholar
  43. 43.
    Timmel J, Kent PS, Holzmueller CG, Paine L, Schulick RD, Pronovost PJ. Impact of the Comprehensive Unit-based Safety Program (CUSP) on safety culture in a surgical inpatient unit. Jt Comm J Qual Patient Saf. 2010;36(6):252–60.CrossRefPubMedGoogle Scholar
  44. 44.
    Sanchez J, Barach P. High reliability organizations and surgical microsystems: re-engineering surgical care. Surg Clin North Am. 2012;92(1):1–14. doi: 10.1016/j.suc.2011.12.005.CrossRefPubMedGoogle Scholar
  45. 45.
    Cuschieri A. Nature of human error: implications for surgical practice. Ann Surg. 2006;244(5):642–8.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ. 2000;320(7237):745–9.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Winlaw D, Large M, Barach P. Leadership, surgeon well-being and other non-technical aspects of pediatric cardiac surgery. Progr Pediatr Cardiol. 2011;32(2):129–33.Google Scholar
  48. 48.
    Wauben LS, Dekker-van Doorn CM, van Wijngaarden JD, et al. Discrepant perceptions of communication, teamwork and situation awareness among surgical team members. Int J Qual Health Care. 2011;23(2):159–66.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Weldon SM, Korkiakangas T, Bezemer J, Kneebone R. Communication in the operating theatre. Br J Surg. 2013;100(13):1677–88.CrossRefPubMedGoogle Scholar
  50. 50.
    Clements D, Dault M, Priest A. Effective teamwork in healthcare: research and reality. Healthc Pap. 2007;7 Spec No:26–34.Google Scholar
  51. 51.
    Baker D, Battles J, King H, Salas E, Barach P. The role of teamwork in the professional education of physicians: current status and assessment recommendations. Jt Comm J Qual Patient Saf. 2005;31(4):185–202.CrossRefPubMedGoogle Scholar
  52. 52.
    Ricci MA, Brumsted JR. Crew resource management: using aviation techniques to improve operating room safety. Aviat Space Environ Med. 2012;83(4):441–4.CrossRefPubMedGoogle Scholar
  53. 53.
    Quality AfHRa. TeamSTEPPS® 2.0: introduction. 2014. http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/introduction.html. Accessed 24 Apr 2016.
  54. 54.
    Weld LR, Stringer MT, Ebertowski JS, et al. TeamSTEPPS improves operating room efficiency and patient safety. Am J Med Qual. 2015.Google Scholar
  55. 55.
    Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA. 2010;304(15):1693–700.CrossRefPubMedGoogle Scholar
  56. 56.
    Hines S, Luna K, Lofthus J, et al. Becoming a high reliability organization: operational advice for hospital leaders. Rockville, MD: Agency for Healthcare Research and Quality; 2008.Google Scholar
  57. 57.
    Weick KE, Sutcliffe KM. Managing the unexpected: resilient performance in an age of uncertainty. San Francisco, CA: Jossey Bass; 2007.Google Scholar
  58. 58.
    Chassin MR, Loeb JM. High-reliability health care: getting there from here. Milbank Q. 2013;91(3):459–90.CrossRefPubMedPubMedCentralGoogle Scholar
  59. 59.
    Hollnagel E. The four cornerstones of resilience engineering, vol. 2. Farnham, UK: Ashgate Publications; 2009.Google Scholar
  60. 60.
    Nemeth C, Wears R, Woods D, Hollnagel E, Cook R. Minding the gaps creating resilience in Health Care. In: Battles JB, Keyes MA, Grady ML, Henriksen K, editors. Advances in patient safety: new directions and alternative approaches (vol. 3: performance and tools). Rockville, MD: Agency for Healthcare Research and Quality; 2008.Google Scholar
  61. 61.
    Fairbanks RJ, Wears RL, Woods DD, Hollnagel E, Plsek P, Cook RI. Resilience and resilience engineering in health care. Jt Comm J Qual Patient Saf. 2014;40(8):376–83.CrossRefPubMedGoogle Scholar
  62. 62.
    Berwick DM. The science of improvement. JAMA. 2008;299(10):1182–4.CrossRefPubMedGoogle Scholar
  63. 63.
    Marshall M, Pronovost P, Dixon-Woods M. Promotion of improvement as a science. Lancet. 2013;381(9864):419–21.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2017

Authors and Affiliations

  1. 1.Department of SurgeryStanford Hospital and ClinicsStanfordUSA

Personalised recommendations