Thursday, August 4, 2016


The NSPSS will commence in the am with a discussion on Patient Safety Definitions, Goals and Recommendations. This is a highly condensed version of the summary the group compiled prior to the meeting.

My questions/concerns are in red. I am sure this discussion will be lively.


GOAL: identified and defined essential surgical safety elements and processes, as well as the multiple teams involved responsible for all phases of the surgical care continuum.

 The quest for the achievement of surgical safety occurs in a background of many challenges. Patients often enter this system with complex co-morbidities, poor family support and limited or no health literacy. The healthcare system is challenged by a disjointed system wrought with potential human factor, instrument, equipment, infrastructure and other system failures. The possibilities for technical and non-technical slips, lapses or mistakes are endless. Transitions between phases of surgical care are plagued with loss of critical patient information and propagation of misinformation. While multiple professions are charged with the responsibility of coordinating challenging aspects of surgical care, surgeons are "uniquely obligated ethically and professionally to serve as the patient's navigator and advocate".

Important safety element to optimize implementation of safety cultures:

1 . Surgical leadership must optimize team performance and advocate a 'Culture of Safety' using open respectful communication, setting the expectations, coaching towards performance improvement, managing / facilitation conflicts.

2.  Surgical leaders must perfect non-technical skills via establishment of psychological safety and advocating a shared mental model, utilize standardized evidence based surgical clinical pathways, adopting locally endorsed checklists, collect and follow safety data, endorse high reliability principles in surgical teams (see below).

3.  Surgical leaders endorse the use of safety technology demonstrated to reduce patient harm (??)

4.  Surgical leaders are committed to the establishment and maintenance of safe surgical environment thru policies and values which provide core surgical teams with the skills and knowledge to proceed safely, optimize team performance including minimization of fatigue effects, optimize nurse-patient ratios, maintain an undistracted situationally aware team via elimination of distractions, prioritize safety as essential, assuring the sufficiency of supplies, equipment, etc.

To assure everyone is on the same page, the workgroup utilized these definitions for consistency:

1.       ADVERSE EVENT: any event during episode of care directly or indirectly resulting in temporary or permanent harm

2.       NEAR MISS EVENT: event risking patient harm

3.       WRONG EVENT SURGERY- wrong site surgery-wrong patient, wrong surgical side, wrong spinal level, wrong implant or wrong procedure.


a.  Pre occupation with failure: the organization acknowledges the inevitability / potential for failure and therefore has a grasp of human fallibility, system complexity, ambiguity, uncertainty, limitations of training effects of distraction and fatigue, dynamic conditions, time constraints and system vulnerabilities. They focus on potential or actual adverse events. Their incident reporting system is designed for organizational learning and improvement (not punitive).

b.  Sensitive to operations: they continually evaluate local operational team and system performance with focus on the successful and failed intervention.

c.    Reluctance to simplify: they do not simply accept the first or easiest explanation to the etiology of adverse event but investigate these thoroughly to find out "what went wrong" as opposed to "who went wrong".

d.    Commitment to resilience: knowing that errors are inevitable, they have adaptable team and redundancies to mitigate risks of harm preventing disruption of routine workflow.

e.  Deference to expertise: use of team situational leaders who speak up (and are listened to) when they have concerns.

5.   CULTURE OF SAFETY: accepts that the environment is high risk and error prone, maintains a blame free structure support, encourages collaboration without hierarchy, willingness to direct needed resources to address safety concerns, and is vigilant towards improving they environment while expecting untoward events.

6.   SURGICAL TEAM: group of care providers responsible for providing direct care during multiple specific phases of surgical care (i.e. preoperative, immediate preoperative, intraoperative, postoperative and discharge phases). The core team always includes the surgeon, patient and the patient’s family.


a. Preoperatively:

i.    Surgeon / patient shared decision making and informed consent at educational level / language appropriate for the patient; Medical comorbidity and lifestyle optimization (when possible); risk assessment using available tools (ACS/NSQIP calculators); Hospital approved preoperative safety element (lab/x-ray guidelines, HP etc.).

ii.   Site Marked: Utilize a uniform standard surgical site marking using surgeons INITIALS on the PLANNED SURGICAL SITE in the pre-op holding area immediately before (WHAT?) the planned surgery with confirmation by an alert and informed patient.

b. Immediate preoperative phase: assess readiness just prior to the patient being brought into the OR utilizing hospital and provider approved preoperative surgical bundles designed to eliminate errors, optimize patient outcomes and reduce excessive variability in clinical practice-that is if every surgeon then does something different it is next to impossible for the nurses to participate safely in safety checklist support (especially if there are staff rotation or new staff). By obtaining consistency the nurses theoretically spend less time on the variable and more on the patient. Having said that variability can be expected depending on the case type and patient type. WHERE AND HOW IS THIS DONE? Bedside briefing? This may not be possible in many institutions where workload production is the highest priority and the surgeons are pulled in many different directions (OR, Ward, Office, administrative duties...).

c. Intra-operative:

 i. OR safety Processes (safe patient positioning/padding, secure transfers, fire and burn safety)

ii. Distraction Free surgical environment: enforced by policy.

iii. OR SURGICAL CHECKLIST (why is this here? What does this mean?)

iv. Team Brief- surgeon led discussion prior to the case - before induction of anesthesia with all surgical team members present. (where? w/ whom?) Discuss specific needs, special concerns, and contingencies; using a shared mental model w/ psychological safety; review of essential elements of checklist (pt id, procedure, consent, site mark, anesthesia checklist, allergies, blood products, etc.)

 v. Surgical Time Out with a check list- Surgeon announced, full stop, full engagement (Introductions- encouraged by not mandated, should not disrupt flow such as anesthesia demands- the patient is asleep or anxious so the faster this goes the better). Patient name, BD/SSN, consent present, site marked. Anesthesia confirmation of abx.

vi. De-brief:  Procedure name, sponge count, specimen labels, disposition plans. (then what went well, what needs to be changed, what will we do differently?)

vii. Use of Surgical Bundles: hypothermia, glucose control, VTE P, ABX, Intraop medication use, wound management, team safety, sponge counts, Patient disposition.

d. Postoperative Surgical Care bundles.

e. Cross phase tools: Consistent, unambiguous, effective, succinct hand off communication.



1.      Consistent use of all communications tools contained in the OR surgery checklist- surgical team brief, surgical team time out and surgical team de-brief- with active participation by all surgical team members for all surgical patients and surgical procedures in all surgical settings.

2.      All surgical facilities must provide regular OR-SC training and education programs with compliance monitoring to assess proper use by all surgical team members.

3.      Surgeon leadership supported by administrative facility safety commitment is key to development, implementation and maintenance of effective OR-SC use.

4.      Surgical facilities should develop and implement OR SC based on the WHO model with local modifications as appropriate.

B.      SITE MARKING: Site marking policies and programs should include:

1.      The surgeon OR A DESIGNATED LICENSED INDEPENDENT MEDICAL PRACTITIONER, should correctly identify, verify and INITIAL the planned surgical procedure site.

2.      SS marking is best performed in the pre-surgical OR holding area immediately before the surgical procedure.

3.      Site should be marked with surgeons initials (blue or black indelible ink in legible block style letters) directly over the location of the planned surgical procedure (where it will be clearly visible within the surgical field following positioning, prepping and draping) with simultaneous verification of the planned surgical site and surgical procedure by an alert informed patient prior to sedation and surgery. DO NOT USE X’s, Yes’s or No’s.

C.      SHARED DECISION MAKING BETWEEN THE PATIENT and THE SURGEON: Patient is invited by the surgeon to share in the decision making including discussions behind the reason for surgery, alternative treatment options, beneficial outcomes and RISKS, options for choice of surgical facility, disclosure of surgeon performing the procedure, discussion regarding Advanced Directive (resolution of inconsistencies between AD and necessary post-op care), time for questions and answers (consider use of a checklist to inform the discussion between the surgeon and patient).

Follow AHRQ limited Health literacy by assuring material is at appropriate educational level, assure comprehension and avoid medical jargon.

ACGME and ABMS should include Share-decision making as requirements for surgical residency and for surgeon credentialing.


1.      The surgeon as the primary patient advocate supported by the surgical team and surgical facility share accountability for an informed, timely and accurate surgical consent document and process.

2.      All errors or ambiguity in a surgical consent must be resolved prior to the patient entering the OR.

3.      All surgical facilities should define and consistently use a standardized safe surgical consent process and document containing:

a.      Patient centered, easily readable, and readily understandable consent form

b.      Use of understandable language and surgical team speak with patients.

c.       Continual use of patient feed-back for improved patient understanding and surgical team verification.

d.      Absence of use of complex medical/legal jargon

e.      The consent process should include comparison and verification of patient name / identity, procedure, and surgical site from the medical record/surgical scheduling document and consent document.

f.        ACGME should include knowledge and training of the surgical consent process as a requirement for surgical residency.

g.      The Joint Commission and similar surgical facility credentialing organizations should include assessment of the surgical consent process as a component of surgical safety programs.

h.      ABMS should include knowledge of the surgical consent process as a requirement for credentialing.

E.      INFORMATION SHARING- “the Handoff”:

1.      All surgical team members should be educated and trained to use standardized communication tools to support accurate and efficient information transfer for all transitions of surgical patient care.

2.      All facilities should adopt, support and monitor use of standardized communication tools to improve the accuracy and efficiency of surgical information transfer during the entire episode of care.

3.      Hand off tools should include:

a.      Distraction free environment (not sure how in facilities where each nurse has more than one patient).

b.      Face to face communication (if this is for call check out that may not be possible and other electronic means should suffice to do that):

c.       Clear unambiguous transfer of responsibility

d.      Opportunity to question, clarify and challenge the information

e.      Written documentation of the transfer.

4.      EMR should support these tools.

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