Surgical Errors

Surgical errors and their impact

Surgical errors continue to be common in hospital settings, contributing to the world's expanding illness burden (Thiels et al., 2015 pg. 515). Surgical treatment has been proved to be critical to patients' lives, highlighting the necessity for more cautious attempts by those involved. Yet, the research on surgical errors is limited since most occurrences go unreported or are not explored (Thiels et al., 2015 pg. 518). This lack of effort has resulted in a lack of quality measures to prevent the recurrence of these errors, which is medically significant (Garca-Pars et al., 2015). Research conducted by the World Health Organization (WHO) has revealed that wrong site surgeries, wrong procedures or wrong person errors are preventable if a set of standards are used to guide procedures in a hospital (2009). Surgical errors, among other medical errors, have led to the need for implementation of patient safety programs as a public health issue (Mehtsun et al., 2013 pg 175-177).

Causes of surgical errors

Surgical errors, by definition, are preventable mistakes that occur in the "theater" during a procedure. Although a patient signs informed consent forms to show that they understand the risks of the surgery, some missteps are unexpected leading to surgical errors. Research has indicated that there are some causes of these errors including incompetence, improper workflow and communication, insufficient preoperative planning, neglect, drug abuse, and fatigue (Thiels et al., 2015). As such, surgical errors occur when there is a lapse of control or quality by the surgeon as would be expected. Nonetheless, some complications arise due to the diversity in the health of patients or due to pre-existing conditions that are beyond the doctor's control. These are not classified as surgical errors, but rather complications depending on the vulnerabilities.

Importance of safety measures and prevention

There needs to be a shift of the mentality of blaming the individual to the enactment of measures to ensure that safety is maintained during surgery. García-París, Coheña-Jiménez, Montaño-Jiménez &Córdoba-Fernández (2015) notes that although humans are susceptible to errors, there are some never events in surgery that can be easily prevented. A study by WHO revealed that implementation of safe procedures for patients during surgery had the potential to reduce the number of deaths by at least half a million (2009). A safety culture should be embraced as part of the medical procedures to achieve consistency in service delivery (Mehtsun et al., 2013 pg 175-177). Both technical and human factors have been shown to contribute to the occurrence of medical errors in hospital settings. This project will aim at establishing the available safety procedures put in place in Sun hospital for the surgical procedures. This will be aligned with the number of reported surgical errors over the past six months to understand their relationship.

Project Charter

Project Aim and Objective

The project aims at addressing the issue of surgical errors in Sun hospital to show their incidences as well as patient safety measures put in place during surgical procedures. The primary goal of the project will be to identify the frequency of surgical errors in the hospital as well as the set methods for preventing such errors from occurring.

Project Outcomes and Benefits

The results of the project will allow a better understanding of the need for patient safety programs designed to prevent the number of surgical errors. Indeed, by addressing the number of surgical errors, the safety training of the medical practitioners involved in surgical procedures will be revealed. Additionally, proper recommendations on improvement of the services will be offered to indicate a gap in patient safety programs. Consequently, the litigation costs due to surgical errors can be reduced significantly as proper procedures will be adhered to. While the research will show the gaps in the hospital, it will also promote the improvement of patient care through proving focus to the management.

Potential Risk Factors

Risk factors are common during research studies, and this will be expected for the project. One of the risks will be resistance from the management, especially in providing the data on the surgical errors. The hospital is not willing to offer their failures to strangers to avoid bad reputations that may compromise their businesses. Another risk factor is the unavailability of the data especially because most of the surgical errors go unreported. Similarly, if the hospital does not use electronic medical records, getting the information from files have been a big hurdle. Lastly, there is a potential risk of failing to find enough participants who would give accurate information regarding the project. Despite these risk factors, we will have enough documentation and motivation to allow continuation of the project.

Project Tracking

Data collection will be based on open-ended questionnaires to the surgeons in the hospital and the nurse involved during surgeries. The responses will be used to assess safety training as well as reporting of medical errors in the hospital. Additionally, the record of the institution will be used to collect data on the number of surgeries and frequency of errors on a per surgeon basis. Using the proposed WHO surgical safety checklist, the responses will be assessed to determine appropriateness (WHO, 2009). Indeed, the list has been shown to improve teamwork among the participants as well as reduce risks associated with perioperative procedures. The qualitative analysis will provide a basis for the implementation of safety programs in the surgery room. Indeed, healthcare services are subject to changes to either meet international standards or provide best practices. Either way, the goal is to ensure that patients are protected and receive the best care in the surgery room. The progress of the project will be tracked using the responses given to determine acceptance of the problems as well as willingness to accept changes. Additionally, follow-up of the project will be done to ensure that the right programs are adopted to increase patient care and minimize surgical errors.

Significance of Project

The project addresses surgical errors which are a crucial determinant for safe service delivery in a hospital setting. Also to encourage the use of joint commission and sentinel events for the hospitals which helps to prevent surgical errors and patient harm. Therefore, the project targets medical practitioners including the nurses, surgeons, and physicians who are involved in the theater. During a surgical procedure, several specialists are mobilized for the surgery to be carried out. Surgical errors can occur due to a lapse along the flow of information from preoperative planning to the final recovery of the patient. For instance, the nurse may fail to review the equipment required for the procedure leading to complications. Also, the surgeon may mark the wrong site for the surgery or take shortcuts that can result in complications for the patient. Regardless of the person involved in the mistake, the patient ends up being compromised which can be life-threatening. As such, the outcomes of this project will be relevant to the team involved in surgical procedures as well as the administration. The head of operations or chief of surgery is responsible for ensuring the right safety programs are implemented to create quality patient care. Through the recommendations offered during the project, the best safety programs can be adopted to reduce the number of surgical errors.

Current State

The present status of "Sun Hospital's" surgical safety practices rely on a multitude of factors. It was found that focusing only on the operating room was not the entire problem, pre- and post-op areas also contributed to the overall errors. The hospital has put in place policies like Surgical Patient Safety System (SURPASS) checklist which was created in 2009 to ensure the errors are not repeated. It is an interdisciplinary team checklist from admission to discharge for all surgical patients (Vries, 2010). Every staff member that encounters a surgical patient is responsible for checking off their tasks as required for their level of care and position. For example, the pre-op nurse will need to check off that all consent forms were signed, the IV has been started, antibiotics are given no sooner than 60 minutes before cut time, and confirming with the patient all crucial information such as allergies or medications. The operating room nurse will check through all the equipment set-up as necessary, emergency supplies on hand, again confirm patient information from pre-op, insert catheter if needed, perform surgical time out, and complete a surgical instrument count before and after.

Lastly, the post-op nurse is responsible for ensuring the patient has recovered and is stable enough to be transferred to their designated unit, monitor IV patency, provide pain management and any other medications as necessary. These examples are minimal and do not include the many other staff members that would be interacting with the patient but would be on the standard checklist. It is mandated that every employee is responsible for a specific portion of the list and it will be completed every time with every patient. Depending on the complexity of the surgery that will be performed the checklist can be shortened or extended accordingly. Understandably, this checklist can be a bit time-consuming and arduous; however, when it comes to patient safety there are no shortcuts. Since inception, the hospital has seen a decrease in surgical errors of 33% overall. Ideally, this number would be zero; however, there are always unknowns. There will be a review of systems and practices soon to quality check current practices and ensure all have up-to-date standards.

References

García-París, J., Coheña-Jiménez, M., Montaño-Jiménez, P., & Córdoba-Fernández, A. (2015). Implementation of the World Health Organisation (WHO) "Safe Surgery Saves Lives" checklist in a podiatric surgery unit in Spain: a single-center retrospective observational study. Patient Safety in Surgery, 9(1), 29. http://doi.org/10.1186/s13037-015-0075-4

Mehtsun, W. T., Ibrahim, A. M., Diener-West, M., Pronovost, P. J., & Makary, M. A. (2013). Surgical never events in the United States. Surgery (United States), 153(4), 465-472. http://doi.org/10.1016/j.surg.2012.10.005

Thiels, C. A., Lal, T. M., Nienow, J. M., Pasupathy, K. S., Blocker, R. C., Aho, J. M., … Bingener, J. (2015). Surgical never events and contributing human factors. Surgery (United States), 158(2), 515-521. http://doi.org/10.1016/j.surg.2015.03.053

Vries, E. N., Prins, H. A., Crolla, R. M., Outer, A. J., Andel, G. V., Helden, S. H., . . . Boermeester, M. A. (2010). Effect of a Comprehensive Surgical Safety System on Patient Outcomes. New England Journal of Medicine, 363(20), 1928-1937. doi:10.1056/nejmsa0911535

WHO. (2009). World Health Organisation (WHO) Guidelines for Safe Surgery 2009 - Safe Surgery Saves Lives. WHO/IER/PSP/2008.08-1E. The Second Global Patient Safety Challenge, 133. http://doi.org/January 13, 2013