Historical development crtitical success factors in surgery
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Transcript of Historical development crtitical success factors in surgery
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Improving Patient Safety in the Dutch OR’s
Johan LangeDepartment of Surgery Erasmus University Medical Center Rotterdam
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Historical development crtitical success factors in surgery
0 21st century
instruments&apparatus
Professional training
medication(anesthetics, AB, heparin)
Risk factors patient
Best practices, protocols(patientsafety)
factor Results
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Patient safety in the Netherlands (reports)
To err is human (Institute of Medicine 1999)
Hier werk je veilig, of je werkt hier niet (VMS; Rein Willems 2004)
TOP I (toezicht preoperatief proces/registratie; IGZ 2007)
Het resultaat telt (prestatieindicatoren IGZ)
Uitgeteld? (Meijsen, Meers 2007) Voorkom schade, werk veilig (OMS,
NVZ, LEVV 2007) Koers op kwaliteit (VWS 2007) TOP II (toezicht peroperatief
proces/registratie; IGZ 2008) Adviesrapport Cie Patiëntveiligheid
NVvH
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Adverse events in the Dutch OR (2005)
45000 adverse events in 1.000.000 operations/year (all specialisms)
25000 adverse events in surgery: 2.5% of operations 10.000 adverse events in surgery: avoidable Probably only 25% is reported 400 mortal adverse events in the OR 130 mortal adverse events in surgery 40%: avoidable: 50 avoidable death in surgery/year
-Report ‘Onbedoelde schade in de Nederlandse ziekenhuizen (Emgo/NIVEL 2007)
-Cuperus-Bosma JM et al. NTvG 2005; 149: 2153-6
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Adverse events in surgery
36% of all adverse events in health care
Avoidable: 40%
>50%: related to the individual surgeon
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Tenerife 1977: 583 death
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Aviation before 1977: autocratic leadership
=
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Incidents in aviation: ‘75% (human factors)-rule’
accident-analysis, blackbox, simulator-research:
‘75% rule’: 75% of incidentscaused by teamwork-failure
(human factors, chain of errors,
human performance limitation)
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Teamwork: shared mental model
Team situational awareness by:
Sharing knowledge:
Goals
Tasks
Responabilities Free flow of information among
crew menbers, without fear of reservation (beware of dependance and hierarchy)
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CRM (Crew Resource Management)
• Obligation: Joint Aviation Requirements
• Coaching instead of autocratic leadership
• Leader-follower roles
• Cross checking (briefing/debriefing, checklists)
• Intervision/peer assessment (blame free-reporting)
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CRM: technically-complex high risk industries
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OR 21st century: technically-complex high risk environment
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Report ‘To err is human’Institute of Medicine USA 1999
"The experiences of other industries provide valuable insight about how to begin the process of improving safety of health care by learning how to prevent, detect, recover and learn from accidents."
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VWS-Report ‘Here you are working safely, or you do not work here at all’‘The safety of Care’ 2004
Recommendations:
1) Safety management system in all hospitals (VMS)
Blamefree incident-reporting
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VWS-Report ‘Here you are working safely, or you do not work here at all’‘The safety of Care’ 2004Rein Willems (CEO Shell) Recommendations:
1) Safety management system in all hospitals (VMS)
Blamefree incident-reporting
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Teamwork in the OR
OR nurses are dissatisfied with communication in the OR
Nestel D, Kidd J. BMC Nursing 2006; 5:1
Feeling like a team member: 75% of surgeons 53% of residents 45% of anesthesiologists 23% of OR-nurses
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team or….
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Ongoing taboos in the OR
Failability of the surgeon Horizontal communication Mistakes (Culture of Name
, Blame and Shame)
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Communication: conflicts
• Conflict between doctors: in 50% of hospitals
• Conflicts with or within other professions: 36%
Source: L.A.P. Arends, i-BMG Erasmus University 2004
Nijmegen
Utrecht
Meppel
Emmeloord/Lelystad
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Autocratic leadership with vertical communication
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Ego’s & culture: idolatry
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CRM: new leadership in the OR-team
Open communication Coaching/Bindend/Sharing Applying protocols and
S.O.P.’s Blamefree reporting
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Professor Rhona Flin (Aberdeen)Behavioural marker observation system for teamwork
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Advantages teambuilding/CRM (non technical-skills)
Respect and trust Horizontal communication Sharing knowledge and
targets Coaching/binding/sharing
leadership Cross checking (protocols,
S.O.P.’s) Peer assessment Culture of transparancy
(blamefree reporting) Improved climate
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Teamperformance: CRM + expertise (scenario-based simulation)
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Teamperformance: CRM + expertise (scenario-based simulation)
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Joint Commission on Accreditation of Healtcare Organizations (JCAHO) Universal Protocol for eliminating wrong site-, wrong procedure-, wrong person-surgery
Time Out-Procedure Right side surgery Type of procedure (protocol) Identification patient
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Wrong side-surgery
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Eye-hospital Rotterdam :disappearance of wrong-side surgery
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2002 2003 2004
jaar
aant
al bijna fout
fout
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TOP (Time Out Procedure)+
Johan Lange, Linda Wauben, Conny Dekker, Geert Kazemier, Jan Klein, Jeroen PetersDepartments of Anesthesiology and Surgery Erasmus MC
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Results pilot TOP+
Duration 1-2’ Compliance high In 15% of operations incidents
can be avoided
Anesthiology assistant: director
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Time Out=double check
Time-Out
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SURPASS (SURgical PAtient Safety System) –perioperative checklist
Validated (Marja Boermeester) Transfermoments (ward-holding-
OR) Stopping rules
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Teamwork (CRM): culture shock/paradigma shift
Transforming individual professionals into a professional team
Changing training/medical education
New shared responsabilities New professional relationships
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Soft??
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Medical eduction/training: teamfunctioning
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Patient safety in the OR: planning
Short term-vision: Bureaucracy-reflex model
Regulations Audit
Long term-vision
Regulations Audit Transparance Teamconcept
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Historical development crtitical success factors in surgery
0 21st century
instruments&apparatus
Professional training
medication(anesthetics, AB, heparin)
Risk factors patient
Best practices, protocols(patientsafety)
factor Results
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Historical development crtitical success factors in surgery
0 21st century
instruments&apparatus
Professional training
medication(anesthetics, AB, heparin)
Risk factors patient
Best practices, protocols(patientsafety)
factor ResultsTeamwork!
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