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Clinical Orthopaedics and Related Research®

Erschienen in:

01.06.2013 | Symposium: Aligning Physician and Hospital Incentives

Critical Roles of Orthopaedic Surgeon Leadership in Healthcare Systems to Improve Orthopaedic Surgical Patient Safety

verfasst von: Calvin C. Kuo, MD, William J. Robb III, MD

Erschienen in: Clinical Orthopaedics and Related Research® | Ausgabe 6/2013

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Abstract

Background

The prevention of medical and surgical harm remains an important public health problem despite increased awareness and implementation of safety programs. Successful introduction and maintenance of surgical safety programs require both surgeon leadership and collaborative surgeon-hospital alignment. Documentation of success of such surgical safety programs in orthopaedic practice is limited.

Questions/purposes

We describe the scope of orthopaedic surgical patient safety issues, define critical elements of orthopaedic surgical safety, and outline leadership roles for orthopaedic surgeons needed to establish and sustain a culture of safety in contemporary healthcare systems.

Methods

We identified the most common causes of preventable surgical harm based on adverse and sentinel surgical events reported to The Joint Commission. A comprehensive literature review through a MEDLINE^® database search (January 1982 through April 2012) to identify pertinent orthopaedic surgical safety articles found 14 articles. Where gaps in orthopaedic literature were identified, the review was supplemented by 22 nonorthopaedic surgical references. Our final review included 36 articles.

Results

Six important surgical safety program elements needed to eliminate preventable surgical harm were identified: (1) effective surgical team communication, (2) proper informed consent, (3) implementation and regular use of surgical checklists, (4) proper surgical site/procedure identification, (5) reduction of surgical team distractions, and (6) routine surgical data collection and analysis to improve the safety and quality of surgical patient care.

Conclusions

Successful surgical safety programs require a culture of safety supported by all six key surgical safety program elements, active surgeon champions, and collaborative hospital and/or administrative support designed to enhance surgical safety and improve surgical patient outcomes. Further research measuring improvements from such surgical safety systems in orthopaedic care is needed.

American Academy of Orthopaedic Surgeons. Surgical Safety Survey. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2011.

Appelbaum PS. Clinical practice. Assessment of patients’ competence to consent to treatment. N Engl J Med. 2007;357:1834–1840.PubMedCrossRef

Armour Forse R, Bramble JD, McQuillan R. Team training can improve operating room performance. Surgery. 2011;150:771–778.PubMedCrossRef

Arora S, Hull L, Sevdalis N, Tierney T, Nestel D, Woloshynowych M, Darzi A, Kneebone R. Factors compromising safety in surgery: stressful events in the operating room. Am J Surg. 2010;199:60–65.PubMedCrossRef

Beamond BM, Beischer AD, Brodsky JW, Leslie H. Improvement in surgical consent with a preoperative multimedia patient education tool: a pilot study. Foot Ankle Int. 2009;30:619–626.PubMedCrossRef

Broom MA, Capek AL, Carachi P, Akeroyd MA, Hilditch G. Critical phase distractions in anaesthesia and the sterile cockpit concept. Anaesthesia. 2011;66:175–179.PubMedCrossRef

Canale ST. Wrong-site surgery: a preventable complication. Clin Orthop Relat Res. 2005;433:26–29.PubMedCrossRef

Capozzi J, Rhodes R, Chen D. Discussing treatment options. J Bone Joint Surg Am. 2009;91:740–742.PubMedCrossRef

Cornoiu A, Beischer AD, Donnan L, Graves S, de Steiger R. Multimedia patient education to assist the informed consent process for knee arthroscopy. ANZ J Surg. 2011;81:176–180.PubMedCrossRef

10.

Crepeau AE, McKinney BI, Fox-Ryvicker M, Castelli J, Penna J, Wang ED. Prospective evaluation of patient comprehension of informed consent. J Bone Joint Surg Am. 2011;93:e114(1–7).

11.

de Vries EN, Prins HA, Crolla RM, den Outer AJ, van Andel G, van Helden SH, Schlack WS, van Putten MA, Gouma DJ, Dijkgraaf MG, Smorenburg SM, Boermeester MA; SURPASS Collaborative Group. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med. 2010;363:1928–1937.PubMedCrossRef

12.

Federal Aviation Administration. Flight crewmember duties. FAR 121.542. Available at: http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=21fa54465a4bfaebbc18090246f44bb4&rgn=div8&view=text&node=14:3.0.1.1.7.20.3.8&idno=14. Accessed October 11, 2012.

13.

Fink AS, Prochazka AV, Henderson WG, Bartenfeld D, Nyirenda C, Webb A, Berger DH, Itani K, Whitehill T, Edwards J, Wilson M, Karsonovich C, Parmelee P. Predictors of comprehension during surgical informed consent. J Am Coll Surg. 2010;210:919–926.PubMedCrossRef

14.

Fukuda H, Imanaka Y, Hirose M, Hayashida K. Factors associated with system-level activities for patient safety and infection control. Health Policy. 2009;89:26–36.PubMedCrossRef

15.

Gawande AA, Thomas EJ, Zinner MJ, Brennan TA. The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery. 1999;126:66–75.PubMedCrossRef

16.

Ginsburg LR, Chuang YT, Berta WB, Norton PG, Ng P, Tregunno D, Richardson J. The relationship between organizational leadership for safety and learning from patient safety events. Health Serv Res. 2010;45:607–632.PubMedCrossRef

17.

Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, Merry AF, Moorthy K, Reznick RK, Taylor B, Gawande AA; Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360:491–499.PubMedCrossRef

18.

James MA, Seiler JG 3rd, Harrast JJ, Emery SE, Hurwitz S. The occurrence of wrong-site surgery self-reported by candidates for certification by the American Board of Orthopaedic Surgery. J Bone Joint Surg Am. 2012;94:e2(1–12).

19.

Johnson MR, Singh JA, Stewart T, Gioe TJ. Patient understanding and satisfaction in informed consent for total knee arthroplasty: a randomized study. Arthritis Care Res (Hoboken). 2011;63:1048–1054.CrossRef

20.

Johnston G, Ekert L, Pally E. Surgical site signing and “time out”: issues of compliance or complacence. J Bone Joint Surg Am. 2009;91:2577–2580.PubMedCrossRef

21.

Khuri SF, Daley J, Henderson W, Barbour G, Lowry P, Irvin G, Gibbs J, Grover F, Hammermeister K, Stremple JF. The National Veterans Administration Surgical Risk Study: risk adjustment for the comparative assessment of the quality of surgical care. J Am Coll Surg. 1995;180:519–531.PubMed

22.

King HB, Battles J, Baker DP, Alonso A, Salas E, Webster J, Toomey L, Salisbury M. TeamSTEPPS™: team strategies and tools to enhance performance and patient safety. In: Henriksen K, Battles J, Keyes M, Grady M, ed. Advances in Patient Safety: New Directions and Alternative Approaches (Vol 3: Performance and Tools). Rockville, MD: Agency for Healthcare Research and Quality; 2008.

23.

Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington DC: National Academy Press; 2000.

24.

Lingard L, Espin S, Whyte S, Regehr G, Baker GR, Reznick R, Bohnen J, Orser B, Doran D, Grober E. Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care. 2004;13:330–334.PubMedCrossRef

25.

Lingard L, Regehr G, Orser B, Reznick R, Baker GR, Doran D, Espin S, Bohnen J, Whyte S. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg. 2008;143:12–17.PubMedCrossRef

26.

McGreevy JM, Otten TD. Briefing and debriefing in the operating room using fighter pilot crew resource management. J Am Coll Surg. 2007;205:169–176.PubMedCrossRef

27.

Miller MJ, Abrams MA, Earles B, Phillips K, McCleeary EM. Improving patient-provider communication for patients having surgery: patient perceptions of a revised health literacy-based consent process. J Patient Saf. 2011;7:30–38.PubMedCrossRef

28.

Neily J, Mills PD, Eldridge N, Carney BT, Pfeffer D, Turner JR, Young-Xu Y, Gunnar W, Bagian JP. Incorrect surgical procedures within and outside of the operating room: a follow-up report. Arch Surg. 2011;146:1235–1239.PubMedCrossRef

29.

Neily J, Mills PD, Eldridge N, Dunn EJ, Samples C, Turner JR, Revere A, DePalma RG, Bagian JP. Incorrect surgical procedures within and outside of the operating room. Arch Surg. 2009;144:1028–1034.PubMedCrossRef

30.

Neily J, Mills PD, Young-Xu Y, Carney BT, West P, Berger DH, Mazzia LM, Paull DE, Bagian JP. Association between implementation of a medical team training program and surgical mortality. JAMA. 2010;304:1693–1700.PubMedCrossRef

31.

Panesar SS, Noble DJ, Mirza SB, Patel B, Mann B, Emerton M, Cleary K, Sheikh A, Bhandari M. Can the surgical checklist reduce the risk of wrong site surgery in orthopaedics? Can the checklist help? Supporting evidence from analysis of a national patient incident reporting system. J Orthop Surg Res. 2011;6:18.PubMedCrossRef

32.

Pereira BM, Pereira AM, Cdos SC, Marttos AC, Fiorelli RK, Fraga GP. Interruptions and distractions in the trauma operating room: understanding the threat of human error. Rev Col Bras Cir. 2011;38:292–298.PubMedCrossRef

33.

Raheja D. Safer Hosptial Care: Strategies for Continuous Innovation. New York, NY: CRC Press; 2011.

34.

Robinson PM, Muir LT. Wrong-site surgery in orthopaedics. J Bone Joint Surg Br. 2009;91:1274–1280.PubMedCrossRef

35.

Rossi MJ, Guttmann D, MacLennan MJ, Lubowitz JH. Video informed consent improves knee arthroscopy patient comprehension. Arthroscopy. 2005;21:739–743.PubMedCrossRef

36.

Salas E, Diaz Granados D, Klein C, Burke CS, Stagl KC, Goodwin GF, Halpin SM. Does team training improve team performance? A meta-analysis. Hum Factors. 2008;50:903–933.PubMedCrossRef

37.

Seiden SC, Barach P. Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable? Arch Surg. 2006;141:931–939.PubMedCrossRef

38.

Sevdalis N, Healey AN, Vincent CA. Distracting communications in the operating theatre. J Eval Clin Pract. 2007;13:390–394.PubMedCrossRef

39.

Sewell M, Adebibe M, Jayakumar P, Jowett C, Kong K, Vemulapalli K, Levack B. Use of the WHO surgical safety checklist in trauma and orthopaedic patients. Int Orthop. 2011;35:897–901.PubMedCrossRef

40.

Stahel PF, Sabel AL, Victoroff MS, Varnell J, Lembitz A, Boyle DJ, Clarke TJ, Smith WR, Mehler PS. Wrong-site and wrong-patient procedures in the universal protocol era: analysis of a prospective database of physician self-reported occurrences. Arch Surg. 2010;145:978–984.PubMedCrossRef

41.

The Joint Commission. Sentinel Event Database. Available at: http://www.jointcommission.org/sentinel_event.aspx. Accessed October 11, 2012.

42.

The Joint Commission. Universal Protocol. Available at: http://www.jointcommission.org/standards_information/up.aspx. Accessed April 22, 2012.

43.

Weaver SJ, Rosen MA, Diaz Granados D, Lazzara EH, Lyons R, Salas E, Knych SA, McKeever M, Adler L, Barker M, King HB. Does teamwork improve performance in the operating room? A multilevel evaluation. Jt Comm J Qual Patient Saf. 2010;36:133–142.PubMed

44.

Wilson NA, Ranawat A, Nunley R, Bozic KJ. Aligning stakeholder incentives in orthopaedics. Clin Orthop Relat Res. 2009;467:2521–2524.PubMedCrossRef

45.

Wong DA, Herndon JH, Canale ST, Brooks RL, Hunt TR, Epps HR, Fountain SS, Albanese SA, Johanson NA. Medical errors in orthopaedics: results of an AAOS member survey. J Bone Joint Surg Am. 2009;91:547–557.PubMedCrossRef

Titel: Critical Roles of Orthopaedic Surgeon Leadership in Healthcare Systems to Improve Orthopaedic Surgical Patient Safety
verfasst von: Calvin C. Kuo, MD
William J. Robb III, MD
Publikationsdatum: 01.06.2013
Verlag: Springer-Verlag
Erschienen in: Clinical Orthopaedics and Related Research® / Ausgabe 6/2013
Print ISSN: 0009-921X
Elektronische ISSN: 1528-1132
DOI: https://doi.org/10.1007/s11999-012-2719-3

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Critical Roles of Orthopaedic Surgeon Leadership in Healthcare Systems to Improve Orthopaedic Surgical Patient Safety

Abstract

Background

Questions/purposes

Methods

Results

Conclusions

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Update Orthopädie und Unfallchirurgie

Springer Medizin

Abstract

Background

Questions/purposes

Methods

Results

Conclusions

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