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The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps

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January 7, 2022

A 52-year-old woman presented for a lumpectomy with lymphoscintigraphy and sentinel lymph node biopsy (SLNB) after being diagnosed with ductal carcinoma in situ (DICS). On the day of surgery, the patient was met in the pre-operative unit by several different providers (pre-operative nurse, resident physician, attending physician, and anethesiology team) to help prepare her for the procedure. In the OR, the surgical team performed two separate time-outs while the patient was being prepped, placed under general anesthesia, and draped.

National Healthcare Quality and Disparities Reports.

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Rockville, MD: Agency for Healthcare Research and Quality.

In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. The 2021 report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.

Association of surgeon-patient sex concordance with postoperative outcomes,

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Wallis CJD, Jerath A, Coburn N, et al. JAMA Surg. 2022;157:146-156.

Gender, racial, and ethnic disparities in healthcare can adversely impact patient safety and lead to poor outcomes. This retrospective study examined surgeon-patient sex discordance and perioperative outcomes among adult patients in Ontario, Canada, undergoing common elective or emergent surgical procedures from 2007 to 2019. Among 1.3 million patients, sex discordance between surgeon and patient was associated with a significant increased likelihood of adverse perioperative outcomes, including death. Subgroup analyses indicate that this relationship is driven by worse outcomes among female patients treated by male surgeons.

Surgical safety checklist audits may be misleading! Improving the implementation and adherence of the surgical safety checklist: a quality improvement project.

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Brown B, Bermingham S, Vermeulen M, et al. BMJ Open Qual. 2021;10:e001593.

Despite evidence of the benefits of the World Health Organization’s surgical safety checklist, implementation and sustainability are inconsistent in many hospitals. Using five cycles of Plan-Do-Study-Act, a hospital in Adelaide, South Australia, was able to increase use of the checklist from 3.5% to 63%. Staff reported that they felt the new checklist process improved patient safety and was easily incorporated into their workflow.

Semantically ambiguous language in the teaching operating room.

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Liu C, McKenzie A, Sutkin G. J Surg Edu. 2021;78:1938-1947.

Communication failures are a common cause of patient harm. This qualitative study found that potentially ambiguous language is common in surgical training settings. In addition to creating challenges for trainee comprehension of surgical instruction, ambiguous language can lead to miscommunications and near misses.

Technology, Education and Safety.

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Ruskin KJ, ed. Curr Opin Anaesthesiol. 2021;34(6):720-765

Anesthesia services are high risk despite progress made in the specialty to improve its safety. This special section covers issues that affect anesthesia safety such as critical incident debriefing, human factors, and educational strategies.

Honesty and transparency, indispensable to the clinical mission-Parts I-III.

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Brenner MJ, Boothman RC, Rushton CH, et al. Otolaryngol Clin North Am. 2021;55.

This three-part series offers an in-depth look into the core values of honesty, transparency, and trust. Part 1, Promoting Professionalism, introduces interventions to increase provider professionalism. Part 2, Communication and Transparency, describes the commitment to honesty and transparency across the continuum of the patient-provider relationship. Part 3, Health Professional Wellness, describes the impact of harm on providers and offers recommendations for restoring wellness and joy in work.

Worldwide incidence of surgical site infections in general surgical patients: a systematic review and meta-analysis of 488,594 patients.

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Gillespie BM, Harbeck EL, Rattray M, et al. Int J Surg. 2021;95:106136.

Surgical site infections (SSI) are a common, yet largely preventable, complication of surgery which can result in increased length of stay and hospital readmission. In this review of 57 studies, the cumulative incidence of SSI was 11% in adult general surgical patients and was associated with increased length of stay (with variation by types of surgery).

Perioperative Safety Collaborative.

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ECRI and Institute for Safe Medication Practices. January 2022 through May 2022.

Collaboratives provide teams with active learning and improvement opportunities based on the experiences of others working toward a collective goal. This collaborative will target safety during surgical procedures. The discussions protected under the sponsors’ Patient Safety Organization status will explore improvement topics such as medication errors and surgical site infections.

Malpractice cases in breast surgery: an assessment of litigation involving surgeons.

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Fan B, Pardo J, Yu-Moe CW, et al. Ann Surg Oncol. 2021;28:8109-8115.

While prior research has described malpractice cases related to breast cancer diagnosis and treatment, this study sought to identify errors specifically related to breast cancer surgical procedures. Plastic surgeons were the most commonly named provider type (64%), error in surgical treatment was the most common allegation (87%), and infection, cosmetic injury, emotional trauma, foreign body, and nosocomial infection were the top 5 injury descriptions.

Inattentional blindness in anesthesiology: a gorilla is worth one thousand words.

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De Cassai A, Negro S, Geraldini F, et al. PLoS One. 2021;16:e0257508.

Inattentional blindness occurs when individuals miss an unexpected event due to competing attentional tasks. This study asked anesthesiologists to review the anesthetic management of five simulated cases, one of which included the image of a gorilla in the radiograph, to evaluate inattentional blindness. Only 4.9% of social media respondents reported an abnormality, suggesting that inattentional blindness may be common; the authors suggest several strategies to reduce this error.

Pediatric medication errors and reduction strategies in the perioperative period.

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Bekes JL, Sackash CR, Voss AL, et al. AANA J. 2021;89(4):319-324.

Pediatric medication errors during anesthesia can lead to significant harm and are largely preventable. This review identifies several themes around medication errors including dosing and incorrect medication. Successful error reduction strategies, such as standardized labeling and pre-filled syringes, are also described.

Impact of the WHO Surgical Safety Checklist relative to its design and intended use: a systematic review and meta-meta-analysis.

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Sotto KT, Burian BK, Brindle ME. J Am Coll Surg. 2021;233:794-809.e8.

The World Health Organization (WHO) Surgical Safety Checklist has been implemented in healthcare systems around the world. This systematic review and thematic analysis concluded that the surgical safety checklist positively impacts clinical outcomes (surgical outcomes and mortality), process measures, team dynamics, and communication, as well as safety culture. The authors note that the checklist was negatively associated with efficiency and workload; included studies often noted that checklist users felt the checklist slowed down processes within the operating room

Surgical teams' attitudes about surgical safety and the surgical safety checklist at 10 years: a multinational survey.

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Urban D, Burian BK, Patel K, et al. Ann Surg. 2021;2:e075.

The WHO surgical safety checklist has been implemented in healthcare systems around the world. Survey responses from 2,032 surgical team members from high-income countries suggest that most respondents perceive the checklist as enhancing patient safety, but that not all team members are engaging with its use or feel confident in their role in the checklist process.

Influence of perioperative handoffs on complications and outcomes.

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Burden AR, Potestio C, Pukenas E. Adv Anesth. 2021;39:133-148.

Handoffs occur several times during a perioperative encounter, increasing the risk of communication errors. Structured handoffs, such as situation-background-assessment-recommendation (SBAR) and checklists, have been shown to improve communication between providers during anesthesia care. The authors discuss how these tools and other processes can improve shared understanding of effective handoffs.

The nature of reported safety events related to care coordination in the operating room setting in a tertiary academic center.

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Krishnan S, Wheeler KK, Pimentel MP, et al. J Healthc Risk Manag. 2022;41:25-29.

Incident reporting systems are used to detect patient safety concerns and determine potential causes and opportunities for improvements. In the perioperative setting of one hospital, insufficient handoffs were the most common event type in the “coordination of care” category. Use of structured handoffs is recommended to improve communication and patient safety.

Patient, surgeon, and health care worker safety during the COVID-19 pandemic.

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Hölscher AH. Ann Surg. 2021;274:681-687.

In 2020, the World Health Organization prioritized healthcare worker safety as a way to maintain patient safety. This article describes several initiatives aimed at protecting surgeons, patients and healthcare workers implemented since the beginning of the COVID-19 pandemic.

Hospital Performance Report.

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Trenton, NJ: New Jersey Department of Health and Senior Services.

Detailing results of an error reporting initiative in New Jersey, these reports explain how consumers can use this information and provides tips for safety when obtaining health care. A section highlights findings related to patient safety indicators.

Awareness of human factors in the operating theatres during the COVID-19 pandemic

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October 27, 2021

Understanding the ways in which human factors, such as non-technical skills, influence individual and team performance can ultimately improve patient safety, particularly in high-intensity settings such as operating rooms.

The Hidden Danger of Unseen Intravenous Catheters

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October 27, 2021

A 6-week-old infant underwent a craniotomy and excision of abnormal brain tissue for treatment of hemimegalencephaly and epilepsy.

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