- Email: [email protected]
The search for safer surgery
International Journal of Surgery (2005) 3, 7e9
www.int-journal-surgery.com
EDITORIAL
The search for safer surgery
The belief that one day it may be possible for the bad experience suffered by a patient in one place to be the source of transmitted learning that benefits future patients in many countries of the world is a powerful element of the vision behind the new WHO World Alliance for Patient Safety. Inadvertent harm to patients occurs quite commonly in all healthcare settings. Not all of it is serious but studies published since the early 1990’s estimate that one in 10 patients who receive healthcare will suffer from preventable harm1e9 (Table 1). When things go wrong in healthcare they can cause suffering both to patients and staff. They also exact a high financial toll. Patients receiving surgical care are no exception with wrong site surgery being a notable example. Wrong site surgery is a broad term that encompasses all surgical procedures performed on the wrong patient, wrong side of the body or at the wrong level of the correctly identified anatomic side.10 When such errors do occur, their impact is often devastating. The attendant media coverage will usually convey the impression of a service unable to avoid such mistakes and of history repeating itself. Health care, including surgical care, would not only be safer but also enjoy higher public confidence if errors like this could be eliminated completely or greatly reduced in number. In the United States of America since 1996, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has initiated a sentinel event policy, that has tracked and compiled information relating to wrong site surgery. Be-
tween 1995 and 2003, 197 wrong site surgery events were reported. The distribution across specialties was11:
41% 20% 14% 11% 14%
orthopaedic general surgery neurosurgical urology other
Early data from pilot work by the National Patient Safety Agency in England and Wales reporting on 44 adverse events associated with surgery suggests a similar pattern of higher risks in surgical specialties such as orthopaedics and general surgery where the correct identification of the site and side for the procedure is essential.12 A number of initiatives have been taken to avoid wrong site surgery, including, in 1998, the American Academy of Orthopaedic Surgeons (AAOS) preoperative surgical site identification programme known as ‘‘sign your site’’.13 This was modelled on the ‘‘operate through your initials’’ campaign instituted by the Canadian Orthopaedic Association in 1994/1996.14 The Veteran’s Health Administration, JCAHO and the Association of Perioperative Registered Nurses have also issued directives and guidance.15e18 The impact of these directives and solutions in the United States of America are currently being evaluated. Other countries e many of which have recently initiated their own guidance on the subject e are seeking international collaboration to ensure that solutions are based on the best evidence available. The World Alliance for Patient Safety
1743-9191/$ - see front matter ª 2005 World Health Organization. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijsu.2005.03.019
8
Editorial Table 1
Data on adverse events in healthcare from several countries
Study
Study focus (date of admissions)
Adverse Number Number of hospital of adverse event rate (%) admissions events
USA (New York State) (Harvard Medical Practice Study) USA (UtaheColorado Study (UTCOS)) USA (UTCOS)a Australia (Quality in Australian Health Care Study (QAHCS))b Australia (QAHCS) 2 UK Denmark New Zealand Canada
Acute care hospitals (1984)
30,195
1133
3.8
Acute care hospitals (1992) Acute care hospitals (1992) Acute care hospitals (1992)
14,565 14,565 14,179
475 787 2353
3.2 5.4 16.6
care hospitals (1992) 14,179 care hospitals (1999e2000) 1014 care hospitals (1998) 1097 care (1998) 6579 and community hospitals (2001) 3720
1499 119 176 849 279
10.6 11.7 9.0 12.9 7.5
Acute Acute Acute Acute Acute
a UTCOS revised using the same methodology as the Quality in Australia Health Care Study (harmonizing the four methodological discrepancies between the two studies). b QAHCS revised using the same methodology as UTCOS (harmonizing the four methodological discrepancies between the two studies).
can help to ensure that this collaboration takes place.
The Alliance was launched in October 2004 and published a forward plan for 2005 covering six major action areas19: A biennial Global Patient Safety Challenge e the first, covering 2005e2006 will focus on
reducing healthcare associated infection and will be called ‘Clean Care is Safer Care’ Patients for Patient Safety e empowering patients to play an active role by bringing together healthcare consumer groups with an interest in patient safety Taxonomy for Patient Safety e developing internationally acceptable patient safety data standards Research for Patient Safety e developing a research needs strategy in order to help focus research effort on gaps in knowledge and evidence. This action area will also support prevalence studies in developing countries Solutions for Patient Safety e helping to disseminate existing solutions and internationally co-ordinating the development of new solutions Reporting and Learning e developing guidelines for countries on the use of information systems and ensuring that data gathered are analysed to give maximum benefit
To deliver these programmes WHO will bring together technical experts from around the world. The organisation will also work closely with senior policy-makers and renowned experts from Member States with a common objective to stop adverse events in all healthcare settings. Like most other areas of healthcare, surgical services deal with many seriously ill patients in a fast-moving, pressured, high-risk environment. It is inevitable that errors will occur. However, a focus on patient safety is important because it offers the opportunity to reduce the impact of
Editorial error when it occurs. The currency of patient safety is saved lives, injuries prevented and tragedies avoided. The World Alliance for Patient Safety seeks to make this currency a global one and help all countries to address the fundamental challenge of making healthcare, including surgery, safer.
References 1. Brennan TA, Leape LL, Laird N, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and negligence in hospitalised patients: results of the Harvard Medical Practice Study. New England Journal of Medicine 1991;324(6):370e7. 2. Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. New England Journal of Medicine 1991; 324(6):377e84. 3. Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The Quality in Australian Health Care Study. Medical Journal of Australia 1995;163:458e71. 4. Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. British Medical Journal 2001;322:517e9. 5. Thomas EJ, Studdert DM, Burstin HR, Orav EJ, Zeena T, Williams EJ, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Medical Care 2000;38(3):261e71. 6. Schioler T, Lipezak H, Pedersen BL, Mogensen TS, Bech KB, Stockmarr A. Danish Adverse Event Study. Incidence of adverse events in hospitals. A retrospective study of medical records. Ugeskr laeger 2001;163(39):5370e8. 7. Davis P, Lay-Yee R, Briant R, Ali W, Scott A, Schug S. Adverse events in New Zealand public hospitals I: occurrence and impact. New Zealand Medical Journal 2002;115(1167):U271. 8. Davis P, Lay-Yee R, Briant R, Ali W, Scott A, Schug S. Adverse events in New Zealand public hospitals II: occurrence and impact. New Zealand Medical Journal 2003;116(1183):U624.
9 9. Baker GR, Norton PG, Flintolf V, Blais R, Brown A, Cox J, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. Canadian Medical Association Journal 2004;179(11):1678e86. 10. Sentinel Events. In: Comprehensive accreditation manual for hospitals: the official handbook. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; November 2000. SE-2; ECRI, ‘‘Operating room risk management,’’ ORRM Surgery 23(August 2000); 1e2. 11. Joint Commission on Accreditation of Healthcare organizations. A follow up review of wrong site surgery. Sentinel Event Alert no 6, !http://www.jcaho.orgO. 12. National Patient Safety Agency. Patient safety alert correct site surgery, !http://www.npsa.nhs.uk/site/ media/documents/885_CSS%20PSA06%20FINAL.pdfO. 13. American Academy of Orthopaedic Surgeons. Advisory statement on wrong-site surgery, !http://www.aaos.org/ wordhtml/papers/advistmt/wrong.htm.O; 1998. 14. Position paper on wrong-sided surgery in orthopaedics. Winnepeg, Manitoba: Canadian Association Committee on Practice and Economics; 1994. 15. Ensuring correct surgery. VHA Directive 2002e2070. Washington, DC: Department of Veterans Affairs; November 2002. 16. The Joint Commission on Accreditation of Healthcare Organisations. Sentinel event alert. Lessons learned. Wrong site surgery, !http://www.jcaho.org/edu.O. 17. Lessons learned: sentinel event trends in wrong-site surgery. Joint Commission Perspectives 2000;20:14. 18. Scheidt RC. Ensuring correct site surgery: patient safety first. The Association of Perioperative Registered Nurses November 2002;76(5):769e82. 19. World Health Organization. World alliance for patient safety: forward programme 2005. World Health Organization; 2004.
Liam Donaldson Department of Health, Room 107, Richmond House, 79 White Hall, London, SW1A 2NS, UK Tel.: C44 207 210 5150; fax: C44 207 210 5407. E-mail address: [email protected]
www.int-journal-surgery.com
EDITORIAL
The search for safer surgery
The belief that one day it may be possible for the bad experience suffered by a patient in one place to be the source of transmitted learning that benefits future patients in many countries of the world is a powerful element of the vision behind the new WHO World Alliance for Patient Safety. Inadvertent harm to patients occurs quite commonly in all healthcare settings. Not all of it is serious but studies published since the early 1990’s estimate that one in 10 patients who receive healthcare will suffer from preventable harm1e9 (Table 1). When things go wrong in healthcare they can cause suffering both to patients and staff. They also exact a high financial toll. Patients receiving surgical care are no exception with wrong site surgery being a notable example. Wrong site surgery is a broad term that encompasses all surgical procedures performed on the wrong patient, wrong side of the body or at the wrong level of the correctly identified anatomic side.10 When such errors do occur, their impact is often devastating. The attendant media coverage will usually convey the impression of a service unable to avoid such mistakes and of history repeating itself. Health care, including surgical care, would not only be safer but also enjoy higher public confidence if errors like this could be eliminated completely or greatly reduced in number. In the United States of America since 1996, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has initiated a sentinel event policy, that has tracked and compiled information relating to wrong site surgery. Be-
tween 1995 and 2003, 197 wrong site surgery events were reported. The distribution across specialties was11:
41% 20% 14% 11% 14%
orthopaedic general surgery neurosurgical urology other
Early data from pilot work by the National Patient Safety Agency in England and Wales reporting on 44 adverse events associated with surgery suggests a similar pattern of higher risks in surgical specialties such as orthopaedics and general surgery where the correct identification of the site and side for the procedure is essential.12 A number of initiatives have been taken to avoid wrong site surgery, including, in 1998, the American Academy of Orthopaedic Surgeons (AAOS) preoperative surgical site identification programme known as ‘‘sign your site’’.13 This was modelled on the ‘‘operate through your initials’’ campaign instituted by the Canadian Orthopaedic Association in 1994/1996.14 The Veteran’s Health Administration, JCAHO and the Association of Perioperative Registered Nurses have also issued directives and guidance.15e18 The impact of these directives and solutions in the United States of America are currently being evaluated. Other countries e many of which have recently initiated their own guidance on the subject e are seeking international collaboration to ensure that solutions are based on the best evidence available. The World Alliance for Patient Safety
1743-9191/$ - see front matter ª 2005 World Health Organization. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijsu.2005.03.019
8
Editorial Table 1
Data on adverse events in healthcare from several countries
Study
Study focus (date of admissions)
Adverse Number Number of hospital of adverse event rate (%) admissions events
USA (New York State) (Harvard Medical Practice Study) USA (UtaheColorado Study (UTCOS)) USA (UTCOS)a Australia (Quality in Australian Health Care Study (QAHCS))b Australia (QAHCS) 2 UK Denmark New Zealand Canada
Acute care hospitals (1984)
30,195
1133
3.8
Acute care hospitals (1992) Acute care hospitals (1992) Acute care hospitals (1992)
14,565 14,565 14,179
475 787 2353
3.2 5.4 16.6
care hospitals (1992) 14,179 care hospitals (1999e2000) 1014 care hospitals (1998) 1097 care (1998) 6579 and community hospitals (2001) 3720
1499 119 176 849 279
10.6 11.7 9.0 12.9 7.5
Acute Acute Acute Acute Acute
a UTCOS revised using the same methodology as the Quality in Australia Health Care Study (harmonizing the four methodological discrepancies between the two studies). b QAHCS revised using the same methodology as UTCOS (harmonizing the four methodological discrepancies between the two studies).
can help to ensure that this collaboration takes place.
The Alliance was launched in October 2004 and published a forward plan for 2005 covering six major action areas19: A biennial Global Patient Safety Challenge e the first, covering 2005e2006 will focus on
reducing healthcare associated infection and will be called ‘Clean Care is Safer Care’ Patients for Patient Safety e empowering patients to play an active role by bringing together healthcare consumer groups with an interest in patient safety Taxonomy for Patient Safety e developing internationally acceptable patient safety data standards Research for Patient Safety e developing a research needs strategy in order to help focus research effort on gaps in knowledge and evidence. This action area will also support prevalence studies in developing countries Solutions for Patient Safety e helping to disseminate existing solutions and internationally co-ordinating the development of new solutions Reporting and Learning e developing guidelines for countries on the use of information systems and ensuring that data gathered are analysed to give maximum benefit
To deliver these programmes WHO will bring together technical experts from around the world. The organisation will also work closely with senior policy-makers and renowned experts from Member States with a common objective to stop adverse events in all healthcare settings. Like most other areas of healthcare, surgical services deal with many seriously ill patients in a fast-moving, pressured, high-risk environment. It is inevitable that errors will occur. However, a focus on patient safety is important because it offers the opportunity to reduce the impact of
Editorial error when it occurs. The currency of patient safety is saved lives, injuries prevented and tragedies avoided. The World Alliance for Patient Safety seeks to make this currency a global one and help all countries to address the fundamental challenge of making healthcare, including surgery, safer.
References 1. Brennan TA, Leape LL, Laird N, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and negligence in hospitalised patients: results of the Harvard Medical Practice Study. New England Journal of Medicine 1991;324(6):370e7. 2. Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. New England Journal of Medicine 1991; 324(6):377e84. 3. Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The Quality in Australian Health Care Study. Medical Journal of Australia 1995;163:458e71. 4. Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. British Medical Journal 2001;322:517e9. 5. Thomas EJ, Studdert DM, Burstin HR, Orav EJ, Zeena T, Williams EJ, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Medical Care 2000;38(3):261e71. 6. Schioler T, Lipezak H, Pedersen BL, Mogensen TS, Bech KB, Stockmarr A. Danish Adverse Event Study. Incidence of adverse events in hospitals. A retrospective study of medical records. Ugeskr laeger 2001;163(39):5370e8. 7. Davis P, Lay-Yee R, Briant R, Ali W, Scott A, Schug S. Adverse events in New Zealand public hospitals I: occurrence and impact. New Zealand Medical Journal 2002;115(1167):U271. 8. Davis P, Lay-Yee R, Briant R, Ali W, Scott A, Schug S. Adverse events in New Zealand public hospitals II: occurrence and impact. New Zealand Medical Journal 2003;116(1183):U624.
9 9. Baker GR, Norton PG, Flintolf V, Blais R, Brown A, Cox J, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. Canadian Medical Association Journal 2004;179(11):1678e86. 10. Sentinel Events. In: Comprehensive accreditation manual for hospitals: the official handbook. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; November 2000. SE-2; ECRI, ‘‘Operating room risk management,’’ ORRM Surgery 23(August 2000); 1e2. 11. Joint Commission on Accreditation of Healthcare organizations. A follow up review of wrong site surgery. Sentinel Event Alert no 6, !http://www.jcaho.orgO. 12. National Patient Safety Agency. Patient safety alert correct site surgery, !http://www.npsa.nhs.uk/site/ media/documents/885_CSS%20PSA06%20FINAL.pdfO. 13. American Academy of Orthopaedic Surgeons. Advisory statement on wrong-site surgery, !http://www.aaos.org/ wordhtml/papers/advistmt/wrong.htm.O; 1998. 14. Position paper on wrong-sided surgery in orthopaedics. Winnepeg, Manitoba: Canadian Association Committee on Practice and Economics; 1994. 15. Ensuring correct surgery. VHA Directive 2002e2070. Washington, DC: Department of Veterans Affairs; November 2002. 16. The Joint Commission on Accreditation of Healthcare Organisations. Sentinel event alert. Lessons learned. Wrong site surgery, !http://www.jcaho.org/edu.O. 17. Lessons learned: sentinel event trends in wrong-site surgery. Joint Commission Perspectives 2000;20:14. 18. Scheidt RC. Ensuring correct site surgery: patient safety first. The Association of Perioperative Registered Nurses November 2002;76(5):769e82. 19. World Health Organization. World alliance for patient safety: forward programme 2005. World Health Organization; 2004.
Liam Donaldson Department of Health, Room 107, Richmond House, 79 White Hall, London, SW1A 2NS, UK Tel.: C44 207 210 5150; fax: C44 207 210 5407. E-mail address: [email protected]