Table Of ContentSurgical
Patient Care
Improving Safety,
Quality, and Value
Juan A. Sanchez
Paul Barach
Julie K. Johnson
Jeff rey P. Jacobs
Editors
123
Surgical Patient Care
Juan A. Sanchez • Paul Barach
Julie K. Johnson • Jeffrey P. Jacobs
Editors
Surgical Patient Care
Improving Safety, Quality, and Value
Editors
Juan A. Sanchez Paul Barach
Department of Surgery Clinical Professor
Ascension Saint Agnes Hospital Children’s Cardiomyopathy Foundation
Armstrong Institute for Patient Safety and Kyle John Rymiszewski Research
& Quality Scholar
Johns Hopkins University School of Children’s Hospital of Michigan, Wayne
Medicine State University School of Medicine
Baltimore, MD, USA Detroit, MI, USA
Julie K. Johnson Jeffrey P. Jacobs
Department of Surgery Division of Cardiovascular Surgery
Center for Healthcare Studies Johns Hopkins All Children’s Heart
Institute for Public Health and Medicine Institute
Feinberg School of Medicine Johns Hopkins All Children’s Hospital
Northwestern University Johns Hopkins University
Chicago, IL, USA Saint Petersburg, FL, USA
ISBN 978-3-319-44008-8 ISBN 978-3-319-44010-1 (eBook)
DOI 10.1007/978-3-319-44010-1
Library of Congress Control Number: 2016956252
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Foreword I
Sixteen years ago the Institute of Medicine reported that healthcare in the
United States was not as safe as it should be. The report indicated that as
many as a million people are injured each year and at least 44,000 people, and
perhaps as many as 98,000 people, die in hospitals each year as a result of
medical errors that could have been prevented.1 John James, in an article
published in 2013, estimated the true number of premature deaths associated
with preventable harm to patients at more than 400,000 per year.2 While there
is little information regarding the number of patients associated with surgical
complications, there are 51.43 million inpatient and 534 million outpatient
surgeries performed a year in the United States. One study conducted at a
university teaching hospital with a level 1 trauma designation revealed that
despite mortality rates that compared favorably with national benchmarks, a
prospective examination of surgical patients revealed complication rates that
were 2–4 times higher than those identified in an Institute of Medicine report.5
Almost half of these adverse events were judged contemporaneously by peers
to be due to provider error (avoidable). Errors in care contributed to 38 (30 %)
of 128 deaths. Recognition that provider error contributes significantly to
adverse events presents significant opportunities for improving patient out-
comes. In another study, researchers looked at hospitals enrolled in the
American College of Surgeons National Surgical Quality Improvement
Program. Out of 1500 general surgery patients, 11.3 % were readmitted to the
1 http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/1999/To-Err-is-
Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf
2 James, John A New Evidence-based Estimate of Patient Harms Associated with Hospital
Care, Journal of Patient Safety September 2013 vol 9 No 3 p 122 http://journals.lww.com/
journalpatientsafety/Abstract/2013/09000/A_New,_Evidence_based_Estimate_of_
Patient_Harms.2.aspx
3 National Hospital Discharge Survey: 2010 table, Procedures by selected patient character-
istics—Number by procedure category and age; http://www.cdc.gov/nchs/fastats/inpatient-
surgery.htm. Accessed May 27, 2016.
4 US Outpatient Surgery Passes Inpatient to 53 Million a Year; http://www.tampabay.com/
news/health/us-outpatient-surgery-passes-inpatient-to-53-million-a-year/1124313.
Accessed May 27, 2016
5 Healey MA, Shackford SR, Osler TM, Rogers FB, Burns E. Complications in surgical
patients, Arch Surg. 2002 May;137(5):611–7.
v
vi Foreword I
hospital within 30 days with postoperative complications. Of the readmis-
sions, 22.1 % were due to surgical infections.6
In all locations across this country where surgical intervention takes place,
despite the implementation of several specific interventions such as the use of
checklists, pre-op briefings, time-out procedures, and debriefings, significant
progress in keeping patients free from harm has not been made. It is reported
that 40 wrong patient, wrong site, wrong side, and wrong procedure surgeries
occur weekly in the United States.7,8
All practitioners approach their profession with the best of intentions.
They want to provide quality care to the patients who come to be healed or to
have their lives saved. The question to be answered is why, despite all these
efforts and billions of dollars, do these statistics continue to reflect a lack of
significant progress to create a safe surgical environment? Surgery is a very
complex environment and Atul Gawande, MD, MPH, captured the reality of
this by stating “In surgery, you couldn’t have people who are more special-
ized and you couldn’t have people who are better trained. And yet we see
unconscionable levels of death and disability that could be avoided.”9
The premise of this book is that delivering surgical care is complex, com-
plicated, and requires multidisciplinary collaboration. The editors of this
book have brought together an impressive group of multidisciplinary authors
representing a global perspective on safety, quality, and reliability across the
continuum of care for the surgical patient.
Healthcare reform has brought many changes to healthcare; the focus on
accountability for quality (value-based reimbursement) instead of volume has
had an impact on the outcomes of surgical care as viewed by providers, pay-
ers, patients, and their families. This shift cannot occur without a change in
the culture. The authors recognize that system-wide and deep human factors
training are fundamental to developing the teamwork and robust communica-
tions that are essential to create a high-reliability organization focused on
preventing harm to patients. The important connection between patient and
healthcare worker safety, often overlooked, is highlighted and included in the
review of the fundamental principles of the science of safety.
There are significant challenges to provide safe, high-quality, cost- efficient
care in the high technology environment of the operating room. This book helps
to demystify many of the perioperative never events, patient injuries, and proce-
dural errors that occur in the operating room through the use of evidence-based
information, guidelines, and examples of checklists and forms that will be valu-
able additions to the tool kits for developing high- reliability organizations.
6 http://www.fiercehealthcare.com/story/surgical-patients-bounce-back-post-op-
complications/2012-08-29
One in 10 Surgical Patienhttp://www.fiercehealthcare.com/story/surgical-patients-bounce-
back-post-op-complications/2012-08-29its Readmitted with Postop Complications
7 Project Detail: Wrong Site Surgery Project. Joint Commission Center for Transforming
Healthcare. http://www.centerfortransforminghealthcare.org/projectsdetail.aspx?Project = 3.
Accessed April 22, 2016.
8 Seiden, S., Barach, P. Wrong-side, wrong procedure, and wrong patient adverse events:
Are they preventable? Archives of Surgery, 2006;141:1–9.
9 Gawande AA. How do we heal medicine? (video) TED.com. Filmed March 2012. http://
www.ted.com/talks/atul_gawande_how_do_we_heal_medicine. Accessed May 15, 2016.
Foreword I vii
Healthcare is highly regulated by government agencies, insurers, and vol-
untary agencies. The editors have included an extensive review of the systems
that have been developed and are vital to maximizing patient and healthcare
worker safety; however, they also make the point that each individual practi-
tioners and the leadership of the facility have responsibility and accountabil-
ity to create a harm-free environment. While the systems are an excellent
adjunct to creating a safe environment, they must be scientifically based,
focused on outcomes of care, and make sense and meaning to the users. The
authors identify that a culture of safety must have the active support of the
C-suite and be valued as a top priority and be articulated at the highest level
of the organization including the Board of Directors.
The chapter on “Patients and Families as Coproducers of Safe Outcomes”
identifies the essential role that patients and families have in protecting them-
selves. The reluctance of patients and their advocates to ask questions of
healthcare providers is no longer acceptable. They must be invited and learn
to accept the responsibility to ask questions about their care, and to be very
vigilant about the proposed procedure being planned and to pay attention to
all details of their care. Appropriate questions to ask include, “what proce-
dures are in place to avoid: a wrong site surgery, medication errors, and surgi-
cal site infections?”
The future of surgical care and outcomes is directed by the shift to value-
based reimbursement. This requires that management and clinicians rely on data
in a new way, for example including process improvement projects, measuring
workflow, exploring new systems of delivery of care to the surgical patient, and
the use of registries to improve outcomes. Facilities have a plethora of robust
data that needs to be distilled to make the necessary connections to predictive
analytics. Predictive analytics systems are being used, for instance, to under-
stand which patients are at higher risk for hospital readmission, to reduce hospi-
tal stays after joint replacement, and to anticipate staffing needs which reduce
overtime10 and the relationship between culture and safety outcomes.
This book offers a unique perspective on care of the surgical patient as it
includes contributions from all members of the surgical team including
patients and other scientific disciplines with relevant and valuable applica-
tions for the healthcare field. Surgical Patient Care: Improving Safety, Quality
and Value reflects the goals of all the team members who care for surgical
patients and are focused on advancing on the journey to high reliability of
surgical intervention. This will only be accomplished by day to day recogni-
tion that concern for patient safety must be constant and woven into the val-
ues of the institution. This book is an outstanding resource and I highly
endorse it. It should be a required book in every operating room and hospital
C-suite around the world to assist the surgical team and the hospital l eadership
on their journey to improve safety, quality, and value for surgical patient care.
Linda Groah, MSN, RN
Executive Director and CEO of the Association
of periOperative Registered Nurses
10 Karyn Hede, Moneyball Mindset, H&HN April 2016 p 23
Foreword II
Over the last 40 years, many high-risk industries have made great progress in
managing the challenges of improving safety and reducing harmful events.
They have created the conditions through which errors are considered inevi-
table and provide opportunities to learn and improve; systems are built that
mitigate accidents and prevent them causing serious harm; there is an under-
standing that a human factors approach creates teams of employees trained in
nontechnical as well as their traditional technical and clinical skills. These
changes, and others, have delivered safer air travel, safer nuclear power
plants, and safer construction sites.
The majority of healthcare systems, and the hospitals and other organiza-
tions within them, have talked a good game but they have not embraced these
fundamental changes. The result is that, by 2016, researchers at Johns
Hopkins University were estimating that medical error-related deaths were
the third most common cause of death of Americans, only surpassed by can-
cer and cardiovascular disease.
There is clearly a need to establish much greater understanding, amongst
healthcare professionals, health system leaders, patients, and families, as to
how risks arise in healthcare. Through this will come a more widespread
commitment to change in the way that care is currently designed and deliv-
ered. Too often, patient safety has been an interest of academics and enthusi-
asts and not the mainstream providers of care.
Patient safety thinking and research has tended to become fragmented. It
has taken a number of directions over the last decade: studies have elucidated
the extent of harm to patients and sought to explain its causation; risk and
adverse events have been documented in various clinical specialities (e.g.,
anesthetics), in treatment areas (e.g., medication), in demographic groups
(e.g., neonates), or in settings (e.g., operating rooms); problems with an
established pattern of harm have been reconceptualized and studied in patient
safety terms (e.g., healthcare infection); technological and other solutions to
reduce risk have been evaluated.
Whilst the safety concepts and interventions from other disciplines have
been applied to medicine and healthcare, it is often difficult for students and
practitioners to find the theory, practical implications, evidence-based solu-
tions, and thought leadership in one place.
ix
x Foreword II
This book fills this gap admirably. Although ostensibly about surgery, it
deals with the key themes and concepts in patient safety, many of which are
applicable much more widely across medicine and healthcare. It will be a trusty
companion for surgeons but also those who wish to learn, those who are look-
ing for new research directions, those who aspire to lead, and those who need a
new source of inspiration to reignite their passion for patient safety.
Sir Liam Donaldson
World Health Organisation
Patient Safety Envoy
Foreword III: What Pilots
Can Teach Hospitals and Healthcare
About Patient Safety
Qantas Flight QF32 proved to me the need for leadership and well-trained,
experienced teams. QF32 was a black swan event*, an unexpected, improba-
ble event that had significant outcomes. Engine number two exploded on my
Airbus A380 4 min after take-off from Singapore airport on the 4th of
November 2010. Five hundred pieces of shrapnel cut more than 650 wires,
damaged 21 of the 22 aircraft systems, starting a 4-hour crisis that challenged
the 25 crew and pilots. QF32’s repair was probably the longest and most
expensive in aviation history.
QF32’s resilience was a team win. Within 2 hours of the engine exploding,
about 1000 specialists had amassed to support us from many locations as we
made our approach to Changi airport in Singapore. The last passenger disem-
barked the aircraft after another 2 hours. There was no panic. There were no
injuries. Teams of experts saved the lives of 469 passengers and crew and
saved tens of thousands of family and friends from traumatic stress.
QF32 reinforced our passengers’ perspectives of aviation safety. (1) Our
passengers value the extra training that crews receive in value-added airlines.
The thousands of hours of deliberate practice pilots conduct in simulators
paid dividends. Everyone delivered excellence under pressure without panic.
For me, QF32 reinforced my values that leaders who set a caring culture and
build great teams achieve remarkable outcomes.
When we look deeper, QF32’s success is not due to me, the crew, or the
passengers. The foundation for QF32’s success lies in the special culture and
resilience systems that exist throughout most of the aviation industry.
Pilots and surgical clinicians manage risks and mitigate threats to prevent
death. Both of our industries face threats from technology, the environment,
resources, humanity, and change. When we analyze disasters, we find a same-
ness in the causes. Most aircraft crashes, like the majority of adverse events
in healthcare, are the result of failures in resilience, particularly human errors
in communication, leadership, and decision-making.
The collision of two Boeing 747 jumbo jets at Tenerife in the Canary
Islands in 1977 is the world’s worst aviation accident. Five hundred and
eighty three people perished in this preventable accident, making it also the
* black swan event - a completely unexpected event with significant impact that is usually
inappropriately rationalized because of hindsight bias (after: Taleb, Nassim Nicholas
(2010) [2007]. The Black Swan: the impact of the highly improbable (2nd ed.). London:
Penguin)
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