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Surgery_Schwartz. the Cockpit Management Attitudes Questionnaire, the SAQ consists of a series of ques-tions measuring six domains: teamwork climate, safety climate, job satisfaction, perception of management, stress recognition, and working conditions.The safety climate scale portion of the questionnaire con-sists of the following seven items:• I am encouraged by my colleagues to report any patient safety concerns I may have.• The culture in this clinical area makes it easy to learn from the mistakes of others.• Medical errors are handled appropriately in this clinical area.Brunicardi_Ch12_p0397-p0432.indd 40120/02/19 3:57 PM 402BASIC CONSIDERATIONSPART I0 20 40 60 80 Medication UseContinuum of CareCare PlanningOperative CareInformation ManagementPhysical EnvironmentAssessmentCommunicationLeadershipHuman FactorsPercent of Events (%)Figure 12-2. Root causes of sentinel events 2004 to 2012. (Data from The Joint Commission, 2012.)staff and resources, uncertainty in clinical decision making and


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Surgery_Schwartz. FactorsPercent of Events (%)Figure 12-2. Root causes of sentinel events 2004 to 2012. (Data from The Joint Commission, 2012.)staff and resources, uncertainty in clinical decision making and planning, and oversights in patient preparation.Measuring TeamworkResearch in commercial aviation has demonstrated a strong correlation between better teamwork and improved safety per-formance. Cockpit crew members’ reluctance to question a cap-tain’s judgment has been identified as a root cause of aviation accidents. Good attitudes about teamwork are associated with error-reduction behaviors in aviation, improved patient out-comes in ICUs, and decreased nurse turnover in the OR. It is also associated with higher job satisfaction ratings and less sick time taken from work.The SAQ can be used to measure teamwork and provide benchmarks for departments or hospitals seeking to measure and improve their teamwork climate.20 The SAQ teamwork scores are responsive to interventions that aim to improve


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Surgery_Schwartz. teamwork and provide benchmarks for departments or hospitals seeking to measure and improve their teamwork climate.20 The SAQ teamwork scores are responsive to interventions that aim to improve team-work among operating teams, such as the implementation of ICU checklists, executive walk rounds, and preoperative brief-ing team discussions. The communication and collaboration sections of the SAQ reflect OR caregiver views on teamwork and can be used to distinguish meaningful interventions from impractical and ineffective programs.In a survey of OR personnel across 60 hospitals, the SAQ identified substantial differences in the perception of team-work in the OR depending on one’s role. Physicians frequently rated the teamwork of others as good, while nurses at the same institutions perceived teamwork as poor (Fig. 12-3). Similar 100%87%Surgeon rates OR nurseOR nurse rates surgeon48%90%80%70%60%Percent rating quality of collaborationand communication as high or very


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Surgery_Schwartz. institutions perceived teamwork as poor (Fig. 12-3). Similar 100%87%Surgeon rates OR nurseOR nurse rates surgeon48%90%80%70%60%Percent rating quality of collaborationand communication as high or very high50%40%30%20%10%0%Figure 12-3. Differences in teamwork perceptions between sur-geons and operating room (OR) nurses. (Reproduced with permis-sion from Makary MA, Sexton JB, Freischlag JA, et al. Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder, J Am Coll Surg. 2006 May;202(5):746-752.)discrepancies have been found in ICUs. These discrepancies can be attributed to differences in the communication skills that are valued by surgeons and nurses. For example, nurses describe good collaboration as having their input respected, while physicians describe good collaboration as having nurses who can anticipate their needs and follow instructions. Efforts to improve the communication that takes place between physicians and nurses can directly improve the


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Surgery_Schwartz. collaboration as having nurses who can anticipate their needs and follow instructions. Efforts to improve the communication that takes place between physicians and nurses can directly improve the perception of teamwork and collaboration by the OR team (Table 12-2). Empowering well-respected surgeons to promote principles of teamwork and communication can go a long way toward transforming attitu-dinal and behavioral changes in fellow physicians as well as other members of the surgical team. Surgeons are increasingly encouraging the respectful and timely voicing of concerns of OR personnel.COMMUNICATION TOOLSHigh reliability organizations such as aviation frequently use tools such as prompts, checks, standard operating protocols, and communication interventions such as team briefings and debriefings. These tools identify and mitigate hazards and allow an organization to complete tasks more efficiently. They also foster a culture of open communication and speaking up if a team member


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Surgery_Schwartz. debriefings. These tools identify and mitigate hazards and allow an organization to complete tasks more efficiently. They also foster a culture of open communication and speaking up if a team member senses a safety concern. Safety checks and standardized team discussions serve as prompts to help “engineer out” human error, providing quality assurance and improving information flow. They also can prevent errors related to omissions, which are more likely to occur when there is information overload, multiple steps in a process, repetitions in steps, and planned departures from routine processes, and when there are other interruptions and distractions present while the process is being executed. These same interventions have been shown to improve patient safety in ORs and ICUs.21,22Operating Room Briefings (A Surgical Checklist)Preoperative briefings and checklists, when used appropriately, help to facilitate transfer of information between team members (Table 12-3). A briefing, or


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Surgery_Schwartz. Room Briefings (A Surgical Checklist)Preoperative briefings and checklists, when used appropriately, help to facilitate transfer of information between team members (Table 12-3). A briefing, or checklist, is any preprocedure dis-cussion of requirements, needs, and special issues of the proce-dure. Briefings often are locally adapted to the specific needs of the specialty. They have been associated with an improved safety culture, including increased awareness of wrong-site/wrong-procedure errors, early reporting of equipment prob-lems, reduced operational costs and fewer unexpected delays. In one study, 30.9% of OR personnel reported a delay before the 7Brunicardi_Ch12_p0397-p0432.indd 40220/02/19 3:57 PM 403QUALITY, PATIENT SAFETY, ASSESSMENTS OF CARE, AND COMPLICATIONSCHAPTER 12Table 12-2Percentage of operating room caregivers reporting a high or very high level of collaboration with other members of the operating room teamCAREGIVER POSITION PERFORMING RATING CAREGIVER POSITION


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Surgery_Schwartz. 12-2Percentage of operating room caregivers reporting a high or very high level of collaboration with other members of the operating room teamCAREGIVER POSITION PERFORMING RATING CAREGIVER POSITION BEING RATEDSURGEONANESTHESIOLOGISTNURSECRNASurgeon85848887Anesthesiologist70968992Nurse48638168CRNA58757693The best teamwork scores were recorded by anesthesiologists when they rated their teamwork with other anesthesiologists (“high” or “very high” 96% of the time). The lowest teamwork ratings were recorded by nurses when they rated their teamwork with surgeons (“high” or “very high” 48% of the time).CRNA = certified registered nurse anesthetist.Reproduced with permission from Makary MA, Sexton JB, Freischlag JA, et al. Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder, J Am Coll Surg. 2006 May;202(5):746-752.Table 12-3Five-point operating room briefingWhat are the names and roles of the team members?Is the correct patient/procedure confirmed? (The


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Surgery_Schwartz. of the beholder, J Am Coll Surg. 2006 May;202(5):746-752.Table 12-3Five-point operating room briefingWhat are the names and roles of the team members?Is the correct patient/procedure confirmed? (The Joint Commission Universal Protocol [TIME-OUT])Have antibiotics been given? (if appropriate)What are the critical steps of the procedure?What are the potential problems for the case?Data from Makary MA, Mukherjee A, Sexton JB, et al. Operating room briefings and wrong-site surgery, J Am Coll Surg. 2007 Feb; 204(2):236-243.institution of OR briefings, and only 23.3% reported delays after briefings were instituted.23 OR briefings are increasingly being used to ensure evidence-based measures are used, such as the appropriate administration of preoperative antibiotics and deep vein thrombosis (DVT) prophylaxis. Briefings allow personnel to discuss potential problems, before they become a “near miss” or cause actual harm.Operating Room DebriefingsPostprocedural debriefings improve patient


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Surgery_Schwartz. (DVT) prophylaxis. Briefings allow personnel to discuss potential problems, before they become a “near miss” or cause actual harm.Operating Room DebriefingsPostprocedural debriefings improve patient safety by allowing for discussion and reflection on causes for errors and critical incidents that occurred during the case. Errors or critical inci-dents are regarded as learning opportunities rather than cause for punishment. During the debriefing, the team also can discuss what went well during the case and designate a point person to follow up on any proposed actions that result from the discus-sion. In addition, most debriefings include a verification of the sponge, needle, and instrument counts and confirmation of the correct labeling of the surgical specimen.Errors in surgical specimen labeling have not received as much attention as incorrect sponge or instrument counts as an indicator of the quality of communication in the OR. How-ever, an error in communication or during the


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Surgery_Schwartz. labeling have not received as much attention as incorrect sponge or instrument counts as an indicator of the quality of communication in the OR. How-ever, an error in communication or during the hand-off process increases the risk of mislabeling a surgical specimen before its arrival in a pathology laboratory. In one study, this type of identification error occurred in 4.3 per 1000 surgical specimens, which implies an annualized rate of occurrence of 182 misla-beled specimens per year (Fig. 12-5).24 Errors involving speci-men identification can result in delays in care, the need for an additional biopsy or therapy, failure to use appropriate therapy, or therapy administered to the wrong body site, side, or patient. These system failures can lead to significant harm to the patient, costs to the institution, and distrust by a community. Given the frequency of occurrence and the feasibility and validity of mea-suring them, mislabeled surgical specimens may serve as a use-ful indicator of


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Surgery_Schwartz. the institution, and distrust by a community. Given the frequency of occurrence and the feasibility and validity of mea-suring them, mislabeled surgical specimens may serve as a use-ful indicator of patient safety and should be included in any postprocedural debriefing checklist.Sign OutsIn healthcare, information frequently passes to covering provid-ers without prioritizing potential concerns. This makes sign outs a very vulnerable process of care, which can lead to catastrophic events.The term sign out can refer to either the verbal or written communication of patient information to familiarize oncoming physicians about patients who will be under their care. Sign outs should occur whenever a patient’s care setting or provider is changing. When performed well, sign outs help to ensure the transfer of pertinent information. However, previous studies have shown the hand-off process to be variable, unstructured, and prone to error. Common categories of communication fail-ure during sign


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Surgery_Schwartz. transfer of pertinent information. However, previous studies have shown the hand-off process to be variable, unstructured, and prone to error. Common categories of communication fail-ure during sign outs include content omissions, such as failure to mention active medical problems, and failures in the actual communication process, such as leaving illegible or unclear notes (Case 12-3).25 These failures lead to confusion and uncer-tainty by the covering physician during patient care decisions, resulting in the delivery of inefficient and suboptimal care.The use of more structured verbal communication such as the Situational Debriefing Model, otherwise known as SBAR (situation, background, assessment, and recommendation), used by the U.S. Navy, can be applied to healthcare to improve the communication of critical information in a timely and orderly fashion.25 In addition, all sign outs should begin with the state-ment, “In this patient, I am most concerned about . . .” to signal to the


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Surgery_Schwartz. of critical information in a timely and orderly fashion.25 In addition, all sign outs should begin with the state-ment, “In this patient, I am most concerned about . . .” to signal to the healthcare provider on the receiving end the most impor-tant safety concerns regarding that specific patient.ImplementationTools such as checklists, sign outs, briefings, and debrief-ings improve communication between healthcare providers and create a safer patient environment (Fig. 12-6). Although their use in healthcare is still highly variable, specialties that Brunicardi_Ch12_p0397-p0432.indd 40320/02/19 3:57 PM 404BASIC CONSIDERATIONSPART ISurgical Safety ChecklistHas the patient conÿrmed his/her identity, site, procedure, and consent?YesIs the site marked?YesNot applicableYesYesNoYesDifÿcult airway or aspiration risk?NoYes, and equipment/assistance availableRisk of >500ml blood loss (7ml/kg in children)?NoYes, and two IVs/central access and ˜uids plannedConÿrm all team members have


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Surgery_Schwartz. airway or aspiration risk?NoYes, and equipment/assistance availableRisk of >500ml blood loss (7ml/kg in children)?NoYes, and two IVs/central access and ˜uids plannedConÿrm all team members have introduced themselves by name and role.Conÿrm the patient’s name, procedure, and where the incision will be made.Has antibiotic prophylaxis been given within the last 60 minutes?YesNot applicableAnticipated Critical EventsTo Surgeon:What are the critical or non-routine steps?How long will the case take?What is the anticipated blood loss?To Anaesthetist:Are there any patient-speciÿc concerns?To Nursing Team:Has sterility (including indicator results) been conÿrmed?Are there equipment issues or any concerns?YesNurse Verbally Conÿrms:The name of the procedureCompletion of instrument, sponge andneedle countsSpecimen labelling (read specimen labelsaloud, including patient name)Whether there are any equipment problemsto be addressedWhat are the key concerns for recovery andmanagement of this patient?


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Surgery_Schwartz. labelling (read specimen labelsaloud, including patient name)Whether there are any equipment problemsto be addressedWhat are the key concerns for recovery andmanagement of this patient? This checklist is not intended to be comprehensive. Additions and modiÿcations to ÿt local practice are encouraged.(with at least nurse and anaesthetist)(with nurse, anaesthetist and surgeon)(with nurse, anaesthetist and surgeon)© WHO, 2009Before induction of anaesthesiaBefore skin incisionBefore patient leaves operating roomRevised 1 / 2009To Surgeon, Anaesthetist and Nurse:Is essential imaging displayed?Not applicableIs the anaesthesia machine and medicationcheck complete? Is the pulse oximeter on the patient andfunctioning?Known allergy? Does the patient have a: Figure 12-4. World Health Organization’s surgical safety checklist. (Reproduced with permission from World Health Organization Safe Surgery Saves Lives. Available at: http://www.who.int/patientsafety/safesurgery/en/. Accessed November 8,


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Surgery_Schwartz. surgical safety checklist. (Reproduced with permission from World Health Organization Safe Surgery Saves Lives. Available at: http://www.who.int/patientsafety/safesurgery/en/. Accessed November 8, 2012.)Specimennot labeledEmptycontainerIncorrectlateralityIncorrecttissue siteIncorrectpatientnameNo patientnameNo tissuesite0.90.80.70.60.50.40.30.20.10Incidence (per 1000 specimens)Error typeFigure 12-5. Incidence of identification errors observed per 1000 specimens (n = 21,351). (Reproduced with permission from Makary MA, Epstein J, Pronovost PJ, et al. Surgical specimen identification errors: a new mea-sure of quality in surgical care, Surgery. 2007 Apr;141(4):450-455.)have incorporated them, such as intensive care and anesthesia, have made impressive strides in patient safety. Currently, com-munication breakdowns, information loss, hand off, multiple competing tasks, and high workload are considered “annoy-ing but accepted features” of the perioperative environment.20 As physician


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Surgery_Schwartz. com-munication breakdowns, information loss, hand off, multiple competing tasks, and high workload are considered “annoy-ing but accepted features” of the perioperative environment.20 As physician attitudes toward errors, stress, and teamwork in medicine become more favorable toward the common goals of reducing error and improving teamwork and communication, medicine will likely achieve many of the milestones in safety that high-reliability industries such as aviation have already accomplished.COMPREHENSIVE UNIT-BASED SAFETY PROGRAMAs medical care and hospitals continue to expand, the care that is provided to patients is becoming more fragmented. This frag-mentation makes communication more difficult and opportuni-ties for medical errors more common. These problems require common sense solutions, often necessitating a change in the way that care is delivered on the local level. Unit-based meetings to discuss processes that are potentially dangerous for patients can quickly bring


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Surgery_Schwartz. solutions, often necessitating a change in the way that care is delivered on the local level. Unit-based meetings to discuss processes that are potentially dangerous for patients can quickly bring danger areas out into the open. These meetings Brunicardi_Ch12_p0397-p0432.indd 40420/02/19 3:57 PM 405QUALITY, PATIENT SAFETY, ASSESSMENTS OF CARE, AND COMPLICATIONSCHAPTER 12Case 12-3 Inadequate sign out leading to medical errorJosie King was an 18-month-old child who was admitted to Johns Hopkins Hospital in January of 2001 for firstand second-degree burns. She spent 10 days in the pediatric intensive care unit and was well on her way to recovery. She was transferred to an intermediate care floor with the expectation that she would be sent home in a few days.The following week, her central line was removed, but nurses would not allow Josie to drink anything by mouth. Around 1 pm the next day, a nurse came to Josie’s bedside with a syringe of methadone. Although Josie’s mother told the


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Surgery_Schwartz. line was removed, but nurses would not allow Josie to drink anything by mouth. Around 1 pm the next day, a nurse came to Josie’s bedside with a syringe of methadone. Although Josie’s mother told the nurse that there was no order for narcotics, the nurse insisted that the orders had been changed and administered the drug. Josie’s heart stopped, and her eyes became fixed. She was moved to the pediatric intensive care unit and placed on life support. Two days later, on February 22, 2001, she died from severe dehydration.After her death, Josie’s parents, Sorrel and Jay King, were motivated to work with leaders at Johns Hopkins to ensure that no other family would have to endure the death of a child due to medical error. They later funded the Josie King Patient Safety Program and an academic scholarship in the field of safety.A preoperativediscussionincreased myawareness of thesurgical site andside beingoperated on.01020304050Percent of respondents who agreed60708090100The surgical siteof


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Surgery_Schwartz. in the field of safety.A preoperativediscussionincreased myawareness of thesurgical site andside beingoperated on.01020304050Percent of respondents who agreed60708090100The surgical siteof the operationwas clear to mebefore theincision.Decision makingutilized inputfrom relevantpersonnel.Surgery andanesthesiaworked togetheras a well-coordinatedteam.Postbriefing PrebriefingFigure 12-6. Impact of operating room briefings on team-work and communication.should be held on a regular basis and bring together a multidisci-plinary team of physicians, nurses, technicians, social workers, and other staff who can each voice their concerns about safety hazards in their area. This enables all aspects of patient care to be addressed and improved continuously, thereby streamlining and improving patient care.26The implementation of the Comprehensive Unit-based Safety Program (CUSP) involves measurement of a unit’s safety culture prior to starting the program and inclusion of hospital management from


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Surgery_Schwartz. care.26The implementation of the Comprehensive Unit-based Safety Program (CUSP) involves measurement of a unit’s safety culture prior to starting the program and inclusion of hospital management from the start. Having management involved allows for more efficient allocation of resources and allows them to better understand the problems faced by front-line pro-viders. Once CUSP is in place, changes can be made using local wisdom to advance patient care.26 The impact of changes made using CUSP can be measured using both patient outcomes and safety culture data.Implementation of CUSP has been associated with improved patient outcomes, including decreased surgical site infections. In a 2-year study of colorectal patients, where the first year was pre-CUSP implementation and the second year was post-CUSP implementation, there was a 33% decrease in the surgical site infection rate after CUSP.27 In this study, the CUSP group met monthly and came up with a list of interven-tions based on


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Surgery_Schwartz. was post-CUSP implementation, there was a 33% decrease in the surgical site infection rate after CUSP.27 In this study, the CUSP group met monthly and came up with a list of interven-tions based on their experience with these cases, including stan-dardization of skin preparation and warming of patients in the preanesthesia area. This study showed that CUSP can be highly effective in ameliorating patient harm and improving patient care.MEASURING QUALITY IN SURGERYDespite the newfound focus on patient safety in surgery and the number of initiatives being undertaken by many organizations to improve their safety culture, there are few tools to actually measure whether these efforts are effective in reducing the num-ber of errors. Several agencies and private groups have devel-oped criteria to evaluate quality and safety within hospitals.Practice Pattern MeasuresNew quality measures in healthcare focus on the appropriate-ness of medical care.28 These appropriateness indicators are


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Surgery_Schwartz. to evaluate quality and safety within hospitals.Practice Pattern MeasuresNew quality measures in healthcare focus on the appropriate-ness of medical care.28 These appropriateness indicators are doctor-defined and specialty-specific so they are smart and fair. One of the first of these new appropriateness metrics is the aver-age number of tissue blocks a skin cancer (Mohs) surgeon will use to surgically remove a skin cancer. The American College of Mohs Surgeons formalized and endorsed the surgeon metric: average number of blocks a surgeon requires to remove a stan-dardized skin cancer. In a report describing the national distri-bution of surgeons by their mean number of blocks per case, the national average was found to be 1.7 blocks per surgeon. Statistical outlier surgeons had an average four or more blocks per patient. Boundaries of normal variation was determined by expert physician leaders to define an acceptable range and an Brunicardi_Ch12_p0397-p0432.indd 40520/02/19 3:57


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Surgery_Schwartz. four or more blocks per patient. Boundaries of normal variation was determined by expert physician leaders to define an acceptable range and an Brunicardi_Ch12_p0397-p0432.indd 40520/02/19 3:57 PM 406BASIC CONSIDERATIONSPART Iunacceptable range (greater than two standard deviations from the national norm). The American College of Mohs Surgeons sent letters to outliers, letting them know where they stand, and offered coaching and retraining help. The new Mohs surgery metric demonstrates the opportunity to reduce unwarranted clinical variation and lower healthcare costs by simply using clinical wisdom and the power of peer-comparison.Appropriateness measures approach quality differently than traditional quality measures and rely on expert physicians to define the metric and set boundaries of reasonable versus unsafe variation in an individual physician’s practice pattern rel-ative to his or her peers nationally. This concept is being applied to utilization rates of minimally


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Surgery_Schwartz. of reasonable versus unsafe variation in an individual physician’s practice pattern rel-ative to his or her peers nationally. This concept is being applied to utilization rates of minimally invasive surgery in candidate patients as well as rates of physical therapy utilization before elective spine surgery for chronic pain.Agency for Healthcare Research and Quality Patient Safety IndicatorsThe Agency for Healthcare Research and Quality (AHRQ) was created in 1989 as a Public Health Service agency in the Depart-ment of Health and Human Services. Its mission is to improve the quality, safety, efficiency, and effectiveness of healthcare for all Americans. Nearly 80% of the AHRQ’s budget is awarded as grants and contracts to researchers at universities and other research institutions across the country. The AHRQ sponsors and conducts research that provides evidence-based information on healthcare outcomes, quality, cost, use, and access. It has advocated the use of readily available


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Surgery_Schwartz. the country. The AHRQ sponsors and conducts research that provides evidence-based information on healthcare outcomes, quality, cost, use, and access. It has advocated the use of readily available hospital inpatient admin-istrative data to measure healthcare quality. The information helps healthcare decision makers make more informed decisions and improve the quality of healthcare services.29One of the major contributions of the AHRQ is a set of Patient Safety Indicators (PSIs), initially released in 2003 and revised in 2010. PSIs are a tool to help health system leaders identify potential adverse events occurring during hospitaliza-tion. Developed after a comprehensive literature review, analy-sis of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes, review by a clini-cian panel, implementation of risk adjustment, and empirical analyses, these 27 indicators provide information on potential in-hospital complications and adverse events


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Surgery_Schwartz. codes, review by a clini-cian panel, implementation of risk adjustment, and empirical analyses, these 27 indicators provide information on potential in-hospital complications and adverse events following surger-ies, procedures, and childbirth (Table 12-4).Provider-level indicators provide a measure of the poten-tially preventable complications for patients who received their initial care and the complication of care within the same hos-pitalization. They include only those cases where a secondary diagnosis code flags a potentially preventable complication. Area-level indicators capture all cases of the potentially pre-ventable complications that occur in a given area (e.g., metro-politan area or county), either during their initial hospitalization or resulting in subsequent hospitalization.30Currently, PSIs are considered indicators, not definitive measures, of patient safety concerns. They can identify potential safety problems that merit further investigation. They also can be used


Surgery_Schwartz

Surgery_Schwartz. PSIs are considered indicators, not definitive measures, of patient safety concerns. They can identify potential safety problems that merit further investigation. They also can be used to better prioritize and evaluate local and national initiatives, and even as benchmarks for tracking progress in patient safety. In the future, further growth in electronic health data will make administrative data-based tools like the PSIs more useful.31The Surgical Care Improvement Project MeasuresThe Surgical Care Improvement Project (SCIP) was established in 2003 by a national partnership of organizations committed Table 12-4Agency for Healthcare Research and Quality patient safety indicatorsProvider-level patient safety indicators• Complications of anesthesia• Death in low mortality diagnosis-related groups• Decubitus ulcer• Failure to rescue• Foreign body left in during procedure• Iatrogenic pneumothorax• Selected infections due to medical care• Postoperative hip fracture• Postoperative


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Surgery_Schwartz. groups• Decubitus ulcer• Failure to rescue• Foreign body left in during procedure• Iatrogenic pneumothorax• Selected infections due to medical care• Postoperative hip fracture• Postoperative hemorrhage or hematoma• Postoperative physiologic and metabolic derangements• Postoperative respiratory failure• Postoperative pulmonary embolism or deep vein thrombosis• Postoperative sepsis• Postoperative wound dehiscence in abdominopelvic surgical patients• Accidental puncture and laceration• Transfusion reaction• Birth trauma—injury to neonate• Obstetric trauma—vaginal delivery with instrument• Obstetric trauma—vaginal delivery without instrument• Obstetric trauma—cesarean deliveryArea-level patient safety indicators• Foreign body left in during procedure• Iatrogenic pneumothorax• Selected infections due to medical care• Postoperative wound dehiscence in abdominopelvic surgical patients• Accidental puncture and laceration• Transfusion reaction• Postoperative hemorrhage or hematomaReproduced


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Surgery_Schwartz. due to medical care• Postoperative wound dehiscence in abdominopelvic surgical patients• Accidental puncture and laceration• Transfusion reaction• Postoperative hemorrhage or hematomaReproduced with permission from Agency for Healthcare Research and Quality. Patient Safety Indicators Overview. AHRQ Quality Indicators. Rockville, MD: Agency for Healthcare Research and Quality; February 2006. Available at: https://www.qualityindicators.ahrq.gov/. Accessed October 24, 2018.to improving surgical care by reducing surgical complications. The steering committee is comprised of groups such as the Centers for Medicare & Medicaid Services, the American Hos-pital Association, Centers for Disease Control and Prevention (CDC), Institute for Healthcare Improvement, The Joint Com-mission, and others.The incidence of postoperative complications ranges from 6% for patients undergoing noncardiac surgery to more than 30% for patients undergoing high-risk surgery. Common post-operative complications


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Surgery_Schwartz. incidence of postoperative complications ranges from 6% for patients undergoing noncardiac surgery to more than 30% for patients undergoing high-risk surgery. Common post-operative complications include surgical site infections (SSIs), myocardial infarction, postoperative pneumonia, and thrombo-embolic complications. Patients who experience postoperative complications have increased hospital length of stay (3 to 11 days longer than those without complications), increased hospital costs (ranging from $1398 for an infectious complication to $18,310 for a thromboembolic event), and increased mortality (median patient survival decreases by up to 69%).32Despite well-established evidence that many of these adverse events are preventable, failure to comply with standards Brunicardi_Ch12_p0397-p0432.indd 40620/02/19 3:57 PM 407QUALITY, PATIENT SAFETY, ASSESSMENTS OF CARE, AND COMPLICATIONSCHAPTER 12of care known to prevent them results in unnecessary harm to a large number of patients.


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Surgery_Schwartz. 40620/02/19 3:57 PM 407QUALITY, PATIENT SAFETY, ASSESSMENTS OF CARE, AND COMPLICATIONSCHAPTER 12of care known to prevent them results in unnecessary harm to a large number of patients. SCIP has identified three broad areas within surgery where potential complications have a high inci-dence and cost and there is a significant opportunity for pre-vention: SSIs, venous thromboembolism, and adverse cardiac events. The SCIP measures aim to reduce the incidence of these events during the perioperative period by advocating the use of proven process and outcome measures. These process and outcome measures are detailed in Table 12-5.SSIs account for 14% to 16% of all hospital-acquired infections and are a common complication of care, occurring in 2% to 5% of patients after clean extra-abdominal operations and up to 20% of patients undergoing intra-abdominal procedures. By implementing steps to reduce SSIs, hospitals could recog-nize a savings of $3152 and reduction in extended length of


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Surgery_Schwartz. operations and up to 20% of patients undergoing intra-abdominal procedures. By implementing steps to reduce SSIs, hospitals could recog-nize a savings of $3152 and reduction in extended length of stay by 7 days on each patient developing an infection.33Adverse cardiac events occur in 2% to 5% of patients undergoing noncardiac surgery and as many as 34% of patients undergoing vascular surgery. Certain perioperative cardiac Table 12-5The Surgical Care Improvement Project measuresProcess of care performance measuresInfection• Prophylactic antibiotic received within 1 h before surgical incision• Prophylactic antibiotic selection for surgical patients• Prophylactic antibiotics discontinued within 24 h after surgery end time (48 h for cardiac patients)• Cardiac surgery patients with controlled 6 a.m. postoperative serum glucose• Surgery patients with appropriate hair removal• Colorectal surgery patients with immediate postoperative normothermiaVenous thromboembolism• Surgery patients with


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Surgery_Schwartz. 6 a.m. postoperative serum glucose• Surgery patients with appropriate hair removal• Colorectal surgery patients with immediate postoperative normothermiaVenous thromboembolism• Surgery patients with recommended venous thromboembolism prophylaxis ordered• Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 h before surgery to 24 h after surgeryCardiac events• Surgery patients on a β-blocker prior to arrival who received a β-blocker during the perioperative periodProposed outcome measuresInfection• Postoperative wound infection diagnosed during index hospitalizationVenous thromboembolism• Intraor postoperative pulmonary embolism diagnosed during index hospitalization and within 30 d of surgery• Intraor postoperative deep vein thrombosis diagnosed during index hospitalization and within 30 d of surgeryCardiac events• Intraor postoperative acute myocardial infarction diagnosed during index hospitalization and within 30 d of surgeryGlobal


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Surgery_Schwartz. during index hospitalization and within 30 d of surgeryCardiac events• Intraor postoperative acute myocardial infarction diagnosed during index hospitalization and within 30 d of surgeryGlobal measures• Mortality within 30 d of surgery• Readmission within 30 d of surgeryData from The Joint Commission, 2012.events, such as myocardial infarction, are associated with a mortality rate of 40% to 70% per event, prolonged hospitaliza-tion, and higher costs. Appropriately administered β-blockers reduce perioperative ischemia, especially in at-risk patients. It has been found that nearly half of the fatal cardiac events could be preventable with β-blocker therapy.33DVT occurs after approximately 25% of all major surgi-cal procedures performed without prophylaxis, and pulmonary embolism (PE) occurs after 7%. Despite the well-established efficacy and safety of preventive measures, studies show that prophylaxis often is underused or used inappropriately. Both low-dose unfractionated heparin and


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Surgery_Schwartz. after 7%. Despite the well-established efficacy and safety of preventive measures, studies show that prophylaxis often is underused or used inappropriately. Both low-dose unfractionated heparin and low molecular weight heparin have similar efficacy in DVT and PE prevention. Pro-phylaxis using low-dose unfractionated heparin has been shown to reduce the incidence of fatal PEs by 50%.33The SCIP effort provides an infrastructure and guidelines for data collection and quality improvement on a national scale. By achieving high levels of compliance with evidence-based practices to reduce SSIs, venous thromboembolism events, and perioperative cardiac complications, the potential number of lives saved in the Medicare patient population alone exceeds 13,000 annually.32National Surgical Quality Improvement ProgramThe National Surgical Quality Improvement Program (NSQIP) is a measurement program that allows hospitals to sample their rates of postoperative events and compare them to similar


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Surgery_Schwartz. Improvement ProgramThe National Surgical Quality Improvement Program (NSQIP) is a measurement program that allows hospitals to sample their rates of postoperative events and compare them to similar hos-pitals. Created by the Veterans Health Administration (VA) in 1991, NSQIP has been credited with measuring and improving morbidity and mortality outcomes at the VA, reducing 30-day mortality rate after major surgery by 31%, and 30-day postop-erative morbidity by 45% in its first decade.34 Beta testing at 18 non-VA sites from 2001 to 2004 demonstrated the feasibility and utility of the program in the private sector. The program was subsequently expanded to the private sector in 2004 when the American College of Surgeons endorsed the program and encouraged hospital participation to measure and evaluate out-comes on a large scale. A study of 118 hospitals participating in NSQIP between 2005 to 2007 showed that 82% of hospitals decreased their complication rates and there was a decrease in


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Surgery_Schwartz. evaluate out-comes on a large scale. A study of 118 hospitals participating in NSQIP between 2005 to 2007 showed that 82% of hospitals decreased their complication rates and there was a decrease in morbidity of 11% and mortality of 17% annually per hospital.35 Currently, over 400 private-sector U.S. hospitals participate in the program.NSQIP uses a risk-adjusted ratio of the observed to expected outcome (focusing primarily on 30-day morbidity and mortal-ity) to compare the performance of participating hospitals with their peers. The data the program has compiled also can be used to conduct observational studies using prospectively collected information on more than 1.5 million patients and operations. The expansion of NSQIP to the private sector has helped shift the focus from merely preventing the provider errors and sentinel events highlighted by the IOM publication “To Err Is Human” to the larger goal of preventing all adverse postoperative outcomes.Several insights about patient


Surgery_Schwartz

Surgery_Schwartz. the provider errors and sentinel events highlighted by the IOM publication “To Err Is Human” to the larger goal of preventing all adverse postoperative outcomes.Several insights about patient safety have arisen as a result of NSQIP. First, safety is indistinguishable from overall quality of surgical care and should not be addressed separately. Defin-ing quality in terms of keeping a patient safe from adverse out-comes allows the NSQIP data to be used to assess and improve quality of care by making improvements in patient safety. In other words, prevention of errors is synonymous with the reduc-tion of adverse outcomes and can be used as a reliable quality measure. Second, during an episode of surgical care, adverse Brunicardi_Ch12_p0397-p0432.indd 40720/02/19 3:57 PM 408BASIC CONSIDERATIONSPART Ioutcomes, and hence, patient safety, are primarily determined by the quality of the systems of care. Errors in hospitals with higher than expected observed to expected outcomes ratios are


Surgery_Schwartz

Surgery_Schwartz. and hence, patient safety, are primarily determined by the quality of the systems of care. Errors in hospitals with higher than expected observed to expected outcomes ratios are more likely to be from system errors than from provider incom-petence. This underscores the importance of adequate communi-cation, coordination, and teamwork in achieving quality surgical care. Finally, reliable comparative outcomes data are imperative for the identification of system problems. Risk-adjusted rates of adverse outcomes must be compared with those at peer institu-tions to appreciate more subtle system errors that lead to adverse outcomes to prompt changes in the quality of an institution’s processes and structures.The Leapfrog GroupOne of the largest efforts to standardize evidence-based med-icine in the United States is led by The Leapfrog Group, an alliance of large public and private healthcare purchasers rep-resenting more than 37 million individuals across the United States. This healthcare


Surgery_Schwartz

Surgery_Schwartz. the United States is led by The Leapfrog Group, an alliance of large public and private healthcare purchasers rep-resenting more than 37 million individuals across the United States. This healthcare consortium was founded in 2000 with the aim to exert their combined leverage toward improving nation-wide standards of healthcare quality, optimizing patient out-comes, and ultimately lowering healthcare costs. The Leapfrog Group’s strategy to achieve these goals is through providing patient referral, financial incentives, and public recognition for hospitals that practice or implement evidence-based healthcare standards.The healthcare quality and safety practices (leaps) that Leapfrog initially identified to measure healthcare standards were hospital use of computerized physician order entry systems, 24-hour ICU physician staffing, and evidence-based hospital referral (EBHR) standards for five high-risk operations.36 In 2010, after the National Quality Forum (NQF) released its updated


Surgery_Schwartz

Surgery_Schwartz. systems, 24-hour ICU physician staffing, and evidence-based hospital referral (EBHR) standards for five high-risk operations.36 In 2010, after the National Quality Forum (NQF) released its updated Safe Practices for Better Healthcare, Leapfrog added a safe practices leap, which includes eight practices from the NQF report.37Leapfrog collects data on these practices through adminis-tration of an ongoing, voluntary, web-based hospital quality and safety survey. This survey is conducted in 41 regions that cover over half of the U.S. population and 62% of all hospital beds in the country. In 2011, more than 1200 urban, suburban, and rural hospitals participated in the survey. Leapfrog asks for informa-tion on eight high-risk conditions or procedures, including coro-nary artery bypass graft, percutaneous coronary intervention, abdominal aortic aneurysm (AAA) repair, pancreatic resection, and esophagectomy. These procedures were chosen because evidence exists that adherence to certain


Surgery_Schwartz

Surgery_Schwartz. percutaneous coronary intervention, abdominal aortic aneurysm (AAA) repair, pancreatic resection, and esophagectomy. These procedures were chosen because evidence exists that adherence to certain process measures can dramatically improve the outcomes of these procedures. In addi-tion, more than 100 studies also have demonstrated that better results are obtained at high-volume hospitals when undergoing cardiovascular surgery, major cancer resections, and other high-risk procedures. Hospitals fulfilling the EBHR Safety Standard are expected to meet the hospital and surgeon volume criteria shown in Table 12-6. Hospitals that do not meet these criteria but adhere to the Leapfrog-endorsed process measures for coro-nary artery bypass graft surgery, percutaneous coronary inter-vention, AAA repair, and care for high-risk neonates, receive partial credit toward fulfilling the EBHR Safety Standard. Leap-frog purchasers work to recognize and reward hospitals that pro-vide care for their


Surgery_Schwartz

Surgery_Schwartz. repair, and care for high-risk neonates, receive partial credit toward fulfilling the EBHR Safety Standard. Leap-frog purchasers work to recognize and reward hospitals that pro-vide care for their enrollees who meet EBHR standards.35In a recent study, Brooke and associates analyzed whether achieving Leapfrog’s established evidence-based standards for AAA repair, including meeting targets for case volume and Table 12-6Recommended annual volumes: hospitals and surgeons1. Coronary artery bypass graft≥450/1002. Percutaneous coronary intervention≥400/753. Abdominal aortic aneurysm repair≥50/224. Aortic valve replacement≥120/225. Pancreatic resection≥11/26. Esophagectomy≥13/27. Bariatric surgery>100/20Reproduced with permission from The Leapfrog Group. Available at: http://www.leapfroggroup.org/.perioperative β-blocker usage, correlated with improved patient outcomes over time.36 After controlling for differences in hos-pital and patient characteristics, hospitals that implemented a policy


Surgery_Schwartz

Surgery_Schwartz. β-blocker usage, correlated with improved patient outcomes over time.36 After controlling for differences in hos-pital and patient characteristics, hospitals that implemented a policy for perioperative β-blocker usage had an estimated 51% reduction in mortality following open AAA repair cases. Among 111 California hospitals in which endovascular AAA repair was performed, in-hospital mortality was reduced by an estimated 61% over time among hospitals meeting Leapfrog case volume standards, although this result was not statistically significant. These results suggest that hospital compliance with Leapfrog standards for elective AAA repair is an effective means to help improve in-hospital mortality outcomes over time and support further efforts aimed at standardizing patient referral to hospi-tals that comply with evidence-based medicine standards for other surgical procedures.The newest effort of the Leapfrog group is to promote transparency of hospital outcomes using a safety


Surgery_Schwartz

Surgery_Schwartz. to hospi-tals that comply with evidence-based medicine standards for other surgical procedures.The newest effort of the Leapfrog group is to promote transparency of hospital outcomes using a safety scorecard. This information can be viewed at www.hospitalsafetygrade.org.World Health Organization “Safe Surgery Saves Lives” InitiativeIn October 2004, the WHO launched a global initiative to strengthen healthcare safety and monitoring systems by creat-ing the World Alliance for Patient Safety. As part of the group’s efforts to improve patient safety, the alliance implemented a series of safety campaigns that brought together experts in spe-cific problem areas through individual Global Patient Safety Challenges. The second Global Patient Safety Challenge focuses on improving the safety of surgical care. The main goal of the campaign, called Safe Surgery Saves Lives, is to reduce surgical deaths and complications through the universal adaptation of a comprehensive perioperative surgical


Surgery_Schwartz

Surgery_Schwartz. care. The main goal of the campaign, called Safe Surgery Saves Lives, is to reduce surgical deaths and complications through the universal adaptation of a comprehensive perioperative surgical safety checklist in ORs worldwide (Fig. 12-4). In addition to the checklist, the WHO defined a set of uniform measures for national and international surveillance of surgical care to better assess the quantity and quality of surgical care being delivered worldwide.38 At the pop-ulation level, metrics include the number of surgeon, anesthesia, and nurse providers per capita, the number of ORs per capita, and overall surgical case volumes and mortality rates. At the hospital level, metrics include safety improvement structures and a surgical “Apgar score,” a validated method of prognos-ticating patient outcomes based on intraoperative events (i.e., hypotension, tachycardia, blood loss).39National Quality ForumThe National Quality Forum (NQF) is a coalition of health-care organizations that has


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Surgery_Schwartz. outcomes based on intraoperative events (i.e., hypotension, tachycardia, blood loss).39National Quality ForumThe National Quality Forum (NQF) is a coalition of health-care organizations that has worked to develop and implement a national strategy for healthcare quality measurement and Brunicardi_Ch12_p0397-p0432.indd 40820/02/19 3:57 PM 409QUALITY, PATIENT SAFETY, ASSESSMENTS OF CARE, AND COMPLICATIONSCHAPTER 12reporting. Their mission is to improve the quality of American healthcare by setting national priorities and goals for perfor-mance improvement, endorsing national consensus standards for measuring and publicly reporting on performance, and pro-moting the attainment of national goals through education and outreach programs.One of the major contributions of the NQF is the develop-ment of a list of Serious Reportable Events, which are frequently referred to as “never events.”40 According to the NQF, “never events” are errors in medical care that are clearly identifiable,


Surgery_Schwartz

Surgery_Schwartz. of a list of Serious Reportable Events, which are frequently referred to as “never events.”40 According to the NQF, “never events” are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients and that indicate a real problem in the safety and credibility of a healthcare facility. Examples of never events include surgery performed on the wrong body part; a foreign body left in a patient after surgery; a mismatched blood transfusion; a major medication error; a severe pressure ulcer acquired in the hospital; and preventable postoperative deaths. Criteria for inclusion as a never event are listed in Table 12-7. The event must be:• Unambiguous (i.e., the event must be clearly identifiable and measurable, and thus feasible to include in a reporting system);• Usually preventable, with the recognition that some events are not always avoidable, given the complexity of healthcare;• Serious, resulting in death or loss of a body part,


Surgery_Schwartz

Surgery_Schwartz. in a reporting system);• Usually preventable, with the recognition that some events are not always avoidable, given the complexity of healthcare;• Serious, resulting in death or loss of a body part, disability, or more than transient loss of a body function; and• Any one of the following:• Adverse, and/or• Indicative of a problem in a healthcare facility’s safety sys-tems, and/or• Important for public credibility or public accountability.These events are not a reasonable medical risk of under-going surgery that the patient must accept but medical errors that should never happen (Case 12-4). The occurrence of any of these events signals that an organization’s patient safety culture or processes have defects that need to be evaluated and cor-rected (Table 12-8).“NEVER EVENTS” IN SURGERYNever events are errors in medical care that are clearly identifi-able, preventable, and serious in their consequences for patients and that indicate a real problem in the safety and credibility of a


Surgery_Schwartz

Surgery_Schwartz. events are errors in medical care that are clearly identifi-able, preventable, and serious in their consequences for patients and that indicate a real problem in the safety and credibility of a healthcare facility.40 Despite widespread agreement that surgi-cal never events are preventable and despite several national and local programs being launched to decrease them, never 8Table 12-7Surgical “never events”• Surgery performed on the wrong body part• Surgery performed on the wrong patient• Wrong surgical procedure performed on a patient• Unintended retention of a foreign object in a patient after surgery or other procedure• Intraoperative or immediately postoperative death in an ASA Class 1 patientASA = American Society of Anesthesiologists.Reproduced with permission from Serious Reportable Events in Healthcare 2011 Update: A Consensus Report. Washington, DC: National Quality Forum; 2011.Case 12-4 Surgical “never event”In 2002, Mike Hurewitz, a reporter for The Times Union of Albany,


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Surgery_Schwartz. Events in Healthcare 2011 Update: A Consensus Report. Washington, DC: National Quality Forum; 2011.Case 12-4 Surgical “never event”In 2002, Mike Hurewitz, a reporter for The Times Union of Albany, suddenly began vomiting blood 3 days after donating part of his liver to his brother while recovering on a hospital floor in which 34 patients were being cared for by one first-year resident. He aspirated and died immediately with no other physician available to assist the overworked first-year resident.Recognized for its advances in the field of liver trans-plantation, at the time, Mount Sinai Hospital was performing more adult-to-adult live-donor operations than any other hos-pital in the country. But the program was shut down by this event. Mount Sinai was held accountable for inadequate care and was banned from performing any live-donor adult liver transplants for more than 1 year. Of the 92 complaints inves-tigated by the state, 75 were filed against the liver transplant unit, with 62


Surgery_Schwartz

Surgery_Schwartz. and was banned from performing any live-donor adult liver transplants for more than 1 year. Of the 92 complaints inves-tigated by the state, 75 were filed against the liver transplant unit, with 62 involving patient deaths. The state concluded that most of the 33 serious violations exhibited by the hospital occurred within the liver transplant unit.As a result of the investigation, Mount Sinai revamped many of the procedures within its transplant unit. Among the changes, first-year residents no longer staffed the transplant service, two healthcare practitioners physically present in the hospital oversaw the transplant unit at all times, and any page coming from the transplant unit had to be answered within 5 minutes of the initial call. In addition, nurses monitored patients’ vital signs more closely after surgery, transplant sur-geons were required to make postoperative visits to both organ donor and recipient, and each registered nurse was assigned to four patients, rather than six


Surgery_Schwartz

Surgery_Schwartz. more closely after surgery, transplant sur-geons were required to make postoperative visits to both organ donor and recipient, and each registered nurse was assigned to four patients, rather than six or seven. The death also led New York to become the first state to develop guidelines for treating live organ donors. Finally, Mike Hurewitz’s widow became a patient safety advocate, urging stricter controls on live donor programs.events are still a significant problem. A study from Mehtsun and colleagues showed that from October 1990 to October 2010, nationwide there were 9744 paid malpractice claims for never events. Of these, mortality was reported in 6.6%, permanent injury in 33%, and temporary injury in 59%. The cost of the never events totaled $1.3 billion. Also, of physicians who were named in a surgical never event claim, 12.4% were named in a future never events claim.41 Another study in 2010 by The Joint Commission found that wrong-site surgery occurs 40 times per week


Surgery_Schwartz

Surgery_Schwartz. who were named in a surgical never event claim, 12.4% were named in a future never events claim.41 Another study in 2010 by The Joint Commission found that wrong-site surgery occurs 40 times per week nationwide.42 Future directions for decreasing these prob-lems include public reporting of never events by hospitals to increase hospital accountability, more formal training in team-work, and CUSP programs in hospitals that have higher rates of never events to help elucidate the root cause.Retained Surgical ItemsA retained surgical item refers to any surgical item found to be inside a patient after he or she has left the OR, thus requiring a second operation to remove the item.43 Estimates of retained for-eign bodies in surgical procedures range from one case per 8000 to 18,000 operations, corresponding to one case or more each year for a typical large hospital or approximately 1500 cases per year in the United States.44 This estimate is based on an analy-sis of malpractice claims and is


Surgery_Schwartz

Surgery_Schwartz. to one case or more each year for a typical large hospital or approximately 1500 cases per year in the United States.44 This estimate is based on an analy-sis of malpractice claims and is likely to underestimate the true incidence. The risk of having a retained surgical item increases during emergency surgery, when there are unplanned changes in Brunicardi_Ch12_p0397-p0432.indd 40920/02/19 3:57 PM 410BASIC CONSIDERATIONSPART ITable 12-8Four patient events that advanced the modern field of patient safetyPATIENTINSTITUTIONYEAREVENTROOT CAUSEOUTCOMELibby ZionNew York Hospital, New York, NY1984Missed allergy to DemerolPhysician fatigueBell Commission shortened resident work hoursBetsy LehmanDana-Farber Cancer Institute, Boston, MA1994Chemotherapy overdoseLack of medication checks and triggersFired doctor, three pharmacists, 15 nurses; overhauled safety programJosie KingJohns Hopkins Hospital, Baltimore, MD2001Severe dehydrationPoor communicationIncreased safety research fundingMike


Surgery_Schwartz

Surgery_Schwartz. doctor, three pharmacists, 15 nurses; overhauled safety programJosie KingJohns Hopkins Hospital, Baltimore, MD2001Severe dehydrationPoor communicationIncreased safety research fundingMike HurewitzMt. Sinai Hospital, New York, NY2002Inadequate postoperative careInadequate supervisionTransplant program shut down until better patient safety safeguards implementedprocedure (due to new diagnoses encountered in the OR), and in patients with higher body mass index (Table 12-9).44The most common retained surgical item is a surgical sponge, but other items, such as surgical instruments and nee-dles, can also be inadvertently left inside a patient during an operation. Retained surgical sponges are commonly discovered as an incidental finding on a routine postoperative radiograph, but also have been discovered in patients presenting with a mass or abdominal pain. Patients with sponges that were originally left in an intracavitary position (such as inside the chest or abdomen) also can present


Surgery_Schwartz

Surgery_Schwartz. discovered in patients presenting with a mass or abdominal pain. Patients with sponges that were originally left in an intracavitary position (such as inside the chest or abdomen) also can present with complications such as abscess, erosion through the skin, fistula formation, bowel obstruction, hematuria, or the development of a new, tumor-like lesion.Retained surgical needles usually are discovered inciden-tally, and reports of retained needles are uncommon. Retained surgical needles have not been reported to cause injury in the same way that nonsurgical needles (e.g., sewing needles, hypo-dermic needles) have been reported to perforate bowel or lodge in vessels and migrate. However, there have been reports of chronic pelvic pain and ocular irritation caused by retained sur-gical needles. A study of plain abdominal radiographs in pigs has demonstrated that mediumto large-size needles can eas-ily be detected. The decision to remove these retained needles depends on symptoms and


Surgery_Schwartz

Surgery_Schwartz. A study of plain abdominal radiographs in pigs has demonstrated that mediumto large-size needles can eas-ily be detected. The decision to remove these retained needles depends on symptoms and patient preference. Needles smaller than 13 mm have been found to be undetectable on plain radio-graph in several studies, have not been shown to cause injury to vessels or visceral organs, and can probably be left alone.Although the actual incidence of retained surgical instru-ments is unknown, they are retained with far less frequency than surgical sponges. The initial presentation of a retained surgical instrument is most commonly pain in the surgical site or the Table 12-9Risk factors for retained surgical sponges• Emergency surgery• Unplanned changes in procedure• Patient with higher body mass index• Multiple surgeons involved in same operation• Multiple procedures performed on same patient• Involvement of multiple operating room nurses/staff members• Case duration covers multiple nursing


Surgery_Schwartz

Surgery_Schwartz. index• Multiple surgeons involved in same operation• Multiple procedures performed on same patient• Involvement of multiple operating room nurses/staff members• Case duration covers multiple nursing “shifts”sensation of a mass of fullness after a surgical procedure that leads to the discovery of a metallic object on a radiographic study. Commonly retained instruments include the malleable and “FISH” instrument that are used to protect the viscera when closing abdominal surgery.A retained surgical foreign body should be included in the differential diagnosis of any postoperative patient who presents with pain, infection, a palpable mass, or a radiopaque structure on imaging. The diagnosis can usually be made using a com-puted tomographic (CT) scan, and this is often the only test needed. If a retained surgical item is identified in the setting of an acute clinical presentation, the treatment usually is removal of the item. However, if the attempt to remove the retained sur-gical item


Surgery_Schwartz

Surgery_Schwartz. If a retained surgical item is identified in the setting of an acute clinical presentation, the treatment usually is removal of the item. However, if the attempt to remove the retained sur-gical item can potentially cause more harm than the item itself, as in the case of a needle or a small part of a surgical item, then removal is occasionally not recommended. Retained surgical sponges should always be removed.The American College of Surgeons and the Association of Perioperative Registered Nurses, in addition to The Joint Com-mission, have issued guidelines to try to prevent the occurrence of retained surgical items. Current recommendations include the use of standard counting procedures, performing a thorough wound exploration before closing a surgical site, and using only X-ray–detectable items in the surgical wound. These organiza-tions also strongly endorse the completion of a postoperative debriefing after every operation. An X-ray at the completion of an operation is encouraged


Surgery_Schwartz

Surgery_Schwartz. items in the surgical wound. These organiza-tions also strongly endorse the completion of a postoperative debriefing after every operation. An X-ray at the completion of an operation is encouraged if there is any concern for a foreign body based on confusion regarding the counts by even a single member of the OR team or in the presence of a risk factor.Surgical CountsThe benefit of performing surgical counts to prevent the occur-rence of retained surgical items is controversial. The increased risk of a retained surgical item during emergency surgery in the study by Gawande and colleagues appeared to be related to bypassing the surgical count in many of these cases.44 However, in another study, the “falsely correct count,” in which a count is performed and declared correct when it is actually incorrect, occurred in 21% to 100% of cases in which a retained surgical item was found.45 This type of count was the most common circumstance encountered in all retained surgical item cases,


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Surgery_Schwartz. incorrect, occurred in 21% to 100% of cases in which a retained surgical item was found.45 This type of count was the most common circumstance encountered in all retained surgical item cases, which suggests that performing a surgical count in and of itself does not prevent this error from taking place. The counting pro-tocol also imposes significant demands on the nursing staff and Brunicardi_Ch12_p0397-p0432.indd 41020/02/19 3:57 PM 411QUALITY, PATIENT SAFETY, ASSESSMENTS OF CARE, AND COMPLICATIONSCHAPTER 12distracts them from focusing on other primarily patient-centered tasks, often during critical portions of the case.19A retained surgical item can occur even in the presence of a known incorrect count. This event is usually a result of poor communication in which a surgeon will dismiss the incorrect count and/or fail to obtain a radiograph before the patient leaves the OR. Having stronger institutional policies in place in case of an incorrect count (such as requiring a


Surgery_Schwartz

Surgery_Schwartz. dismiss the incorrect count and/or fail to obtain a radiograph before the patient leaves the OR. Having stronger institutional policies in place in case of an incorrect count (such as requiring a mandatory radiograph while the patient is still in the OR) can avoid conflict among caregivers and mitigate the likelihood of a retained surgical item occurring as a result of a known incorrect count.Although there is no single tool to prevent all errors, the development of multiple lines of defense to prevent retained surgical items and universally standardizing and adhering to OR safety protocols by all members of the surgical team will help reduce the incidence of this never event.45 Surgeons should take the lead in the prevention of retained surgical items by avoid-ing the use of small or nonradiologically detectable sponges in large cavities, performing a thorough wound inspection before closing any surgical incision, and having a vested interest in the counting procedure performed by


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Surgery_Schwartz. detectable sponges in large cavities, performing a thorough wound inspection before closing any surgical incision, and having a vested interest in the counting procedure performed by nursing staff. The value of routine radiography to prevent a retained surgical item in emergency cases or when major procedures involving multiple surgical teams are being performed is becoming more apparent.The widely accepted legal doctrine when a foreign body is erroneously left in a patient is that the mere presence of the item in the plaintiff’s body indicates that the patient did not receive proper surgical care. The characteristics of the surgeon and their style, bedside manner, honesty, and confidence demonstrated in the management of the case can go a long way in averting a lawsuit or mitigating damages.Wrong-Site SurgeryWrong-site surgery is any surgical procedure performed on the wrong patient, wrong body part, wrong side of the body, or wrong level of a correctly identified anatomic site. It


Surgery_Schwartz

Surgery_Schwartz. SurgeryWrong-site surgery is any surgical procedure performed on the wrong patient, wrong body part, wrong side of the body, or wrong level of a correctly identified anatomic site. It is dif-ficult to determine the true incidence of wrong-site surgery for several reasons. First, there is no standard definition for what constitutes wrong-site surgery among various healthcare orga-nizations. Another factor is that wrong-site surgery is under-reported by healthcare providers. Finally, the total number of potential opportunities for each type of wrong-site error is unknown. However, various studies show incidences ranging from 1 in 112,994 cases to 1 in 15,500 cases.46 The Washington University School of Medicine suggests a rate of 1 in 17,000 operations, which adds up to approximately 4000 wrong-site surgeries in the United States each year. If these numbers are correct, wrong-site surgery is the third most frequent life-threat-ening medical error in the United States.47Several states


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Surgery_Schwartz. wrong-site surgeries in the United States each year. If these numbers are correct, wrong-site surgery is the third most frequent life-threat-ening medical error in the United States.47Several states now require mandatory reporting of all wrong-site surgery events, including near misses. These data provide some insight into the number of actual errors compared to the number of potential opportunities to perform wrong-site surgery. Of the 427 reports of wrong-site surgery submitted from June 2004 through December 2006 to the Pennsylvania Patient Safety Reporting System, more than 40% of the errors actually reached the patient, and nearly 20% involved comple-tion of a wrong-site procedure.46The risk of performing wrong-site surgery increases when there are multiple surgeons involved in the same operation or multiple procedures are performed on the same patient, espe-cially if the procedures are scheduled or performed on different areas of the body.47 Time pressure, emergency surgery,


Surgery_Schwartz

Surgery_Schwartz. same operation or multiple procedures are performed on the same patient, espe-cially if the procedures are scheduled or performed on different areas of the body.47 Time pressure, emergency surgery, abnor-mal patient anatomy, and morbid obesity are also thought to be risk factors. Communication errors are the root cause in more than 70% of the wrong-site surgeries reported to The Joint Com-mission.46 Other risk factors include receiving an incomplete preoperative assessment; having inadequate procedures in place to verify the correct surgical site; or having an organizational culture that lacks teamwork or reveres the surgeon as someone whose judgment should never be questioned.There is a one in four chance that surgeons who work on symmetric anatomic structures will be involved in a wrong-site error sometime during their careers.47 The specialties most com-monly involved in reporting wrong-site surgeries according to The Joint Commission are orthopedic/podiatric surgery (41%); general


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Surgery_Schwartz. error sometime during their careers.47 The specialties most com-monly involved in reporting wrong-site surgeries according to The Joint Commission are orthopedic/podiatric surgery (41%); general surgery (20%); neurosurgery (14%); urology (11%); and maxillofacial, cardiovascular, otolaryngology, and oph-thalmology (14%).46 Most errors involved symmetric anatomic structures: lower extremities (30%), head/neck (24%), and geni-tal/urinary/pelvic/groin (21%).42 Although orthopedic surgery is the most frequently involved, this may be due to the higher volume of cases performed as well as the increased opportu-nity for lateralization errors inherent in the specialty. In addi-tion, because the American Academy of Orthopaedic Surgeons has historically tried as a professional organization to reduce wrong-site operations, orthopedic surgeons may be more likely to report these events when they do occur.47The Joint Commission Universal Protocol to Ensure Correct SurgeryThe movement to eliminate


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Surgery_Schwartz. wrong-site operations, orthopedic surgeons may be more likely to report these events when they do occur.47The Joint Commission Universal Protocol to Ensure Correct SurgeryThe movement to eliminate wrong-site surgery began among professional orthopedic societies in the mid-1990s, when both the Canadian Orthopaedic Association and the American Acad-emy of Orthopaedic Surgeons issued position statements and embarked on educational campaigns to prevent the occurrence of wrong-site surgery within their specialty.47 Other organiza-tions that issued position statements advocating for the elimina-tion of wrong-site surgery include the North American Spine Society, the American Academy of Ophthalmology, the Asso-ciation of Perioperative Registered Nurses, and the American College of Surgeons. After issuing a review of wrong-site sur-gery in their Sentinel Event Alert in 1998, The Joint Commis-sion made the elimination of wrong-site surgery one of their first National Patient Safety Goals in


Surgery_Schwartz

Surgery_Schwartz. issuing a review of wrong-site sur-gery in their Sentinel Event Alert in 1998, The Joint Commis-sion made the elimination of wrong-site surgery one of their first National Patient Safety Goals in 2003 and adopted a uni-versal protocol for preventing wrong-site, wrong-procedure, and wrong-person surgery in 2004. The protocol has been endorsed by more than 50 professional associations and organizations.A preoperative “time-out” or “pause for the cause” to con-firm the patient, procedure, and site to be operated on before incision was recommended by The Joint Commission and is now mandatory for all ORs in the United States. Elements of the protocol include the following:• Verifying the patient’s identity• Marking the surgical site• Using a preoperative site verification process such as a checklist• Confirming the availability of appropriate documents and studies before the start of a procedure• Taking a brief time-out immediately before skin incision, in which all members of the surgical


Surgery_Schwartz

Surgery_Schwartz. the availability of appropriate documents and studies before the start of a procedure• Taking a brief time-out immediately before skin incision, in which all members of the surgical team actively communicate and provide oral verification of the patient’s identity, surgi-cal site, surgical procedure, administration of preoperative Brunicardi_Ch12_p0397-p0432.indd 41120/02/19 3:57 PM 412BASIC CONSIDERATIONSPART Imedications, and presence of appropriate medical records, imaging studies, and equipment• Monitoring compliance with protocol recommendationsFocusing on individual process components of the uni-versal protocol, such as surgical site marking or the time-out, is not enough to prevent wrong-site surgery. Over a 30-month period in Pennsylvania, 21 wrong-site errors occurred despite the proper use of time-out procedures, with 12 of these errors resulting in complete wrong-site procedures. During the same period, correct site markings failed to prevent another 16 wrong-site


Surgery_Schwartz

Surgery_Schwartz. the proper use of time-out procedures, with 12 of these errors resulting in complete wrong-site procedures. During the same period, correct site markings failed to prevent another 16 wrong-site surgeries, of which six were not recognized until after the procedure had been completed.47Site verification begins with the initial patient encounter by the surgeon, continues throughout the preoperative verifica-tion process and during multiple critical points in the OR, and requires the active participation of the entire operating team, especially the surgeon and anesthesia provider. Based on a recent review of malpractice claims, two-thirds of wrong-site operations could have been prevented by a site-verification protocol.48Despite the proliferation of wrong-site protocols in the last decade, their effectiveness is difficult to measure as the inci-dence of wrong-site surgery is too rare to measure as a rate. Interestingly, the number of sentinel events reported to The Joint Commission has


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Surgery_Schwartz. their effectiveness is difficult to measure as the inci-dence of wrong-site surgery is too rare to measure as a rate. Interestingly, the number of sentinel events reported to The Joint Commission has not changed significantly since the wide-spread implementation of the Universal Protocol in 2004.47 This could be due to an increase in reporting rather than an actual increase in the incidence of wrong-site surgery.The legal treatment of wrong-site surgery is similar to that of surgical items erroneously left in a patient: the mere fact that it occurred indicates that the patient did not receive proper surgical care. A malpractice claim may lead to a settlement or award on verdict in the sixor seven-figure range in 2011 U.S. dollars.41Ultimately, the occurrence of retained surgical items or wrong-site surgery is a reflection of the quality of professional communication between caregivers and the degree of teamwork among the members of the operating team. In addition to stan-dardizing


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Surgery_Schwartz. or wrong-site surgery is a reflection of the quality of professional communication between caregivers and the degree of teamwork among the members of the operating team. In addition to stan-dardizing procedures like the surgical count, instituting man-datory postoperative radiographs in the presence of a known miscount, and reforming the processes of patient identification and site verification, organizations should also strive to create a culture of safety, create independent and redundant checks for key processes, and create a system in which caregivers can learn from their mistakes (Table 12-10).49TRANSPARENCY IN HEALTHCAREDespite a large increase in data being collected about patient safety and harm, much of it is not available to the public or other hospitals. This lack of transparency allows some hos-pitals to continue to practice outdated medicine and, in some cases, puts patients at a higher risk of serious complications. In a study by Mark Chassin, the health commissioner of


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Surgery_Schwartz. allows some hos-pitals to continue to practice outdated medicine and, in some cases, puts patients at a higher risk of serious complications. In a study by Mark Chassin, the health commissioner of New York State, having hospitals publicly disclose their mortality rates for coronary artery bypass graft (CABG) procedures resulted in a 41% decline in mortality from CABGs statewide.50 In this study, when CABG mortality data were initially made public, there was a wide range in cardiac surgery-related mortality from 1% to 18%, depending on the hospital; the standard of care is 2%. The reasons for higher mortality in the poorly performing Table 12-10Best practices for operating room safety• Conduct The Joint Commission Universal Protocol (“time-out”) to prevent wrong-site surgery.• Perform an operating room briefing (checklist) to identify and mitigate hazards early.• Promote a culture of speaking up about safety concerns.• Use a screening X-ray to detect foreign bodies in high-risk


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Surgery_Schwartz. an operating room briefing (checklist) to identify and mitigate hazards early.• Promote a culture of speaking up about safety concerns.• Use a screening X-ray to detect foreign bodies in high-risk cases.• Begin patient sign-outs with the most likely immediate safety hazard.Data from Michaels RK, Makary MA, Dahab Y, et al. Achieving the National Quality Forum’s “Never Events”: Prevention of wrong site, wrong procedure, and wrong patient operations, Ann Surg. 2007 Apr;245(4):526-532.hospitals ranged from poor communication between care teams to one rogue surgeon operating when the surgeon should not have been. The consequence of making this data transparent was that the hospitals held multidisciplinary, CUSP-like meetings, where as a team they decided on the measures to implement for improvement. Through this, over the next year, most hospitals decreased their mortality rate to below 2%. Even the hospital that had an 18% mortality rate decreased it to 7% within 3 years and 1.7% over the


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Surgery_Schwartz. Through this, over the next year, most hospitals decreased their mortality rate to below 2%. Even the hospital that had an 18% mortality rate decreased it to 7% within 3 years and 1.7% over the next several years.Transparency in healthcare is becoming central to the healthcare quality discussion. A new SCIP core measure is pub-lishing practitioner performance, and all Leapfrog survey results are published online where other hospitals and the public can see them. Additionally, different large medical societies, includ-ing the Society for Thoracic Surgery (STS), are encouraging and rewarding practitioners and hospitals that are transparent with their outcomes. Making hospital outcomes transparent makes hospitals accountable to the public for their outcomes and, in the case of New York, caused a radical improvement in the quality of care provided to patients. It also empowers patients by mak-ing them better informed about which hospital they choose for their care, which will further


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Surgery_Schwartz. caused a radical improvement in the quality of care provided to patients. It also empowers patients by mak-ing them better informed about which hospital they choose for their care, which will further incentivize hospitals to improve.Public Reporting and Patient Assessment of CareThe epiphany moment in contemporary healthcare created by the Institute of Medicine report2 generated far-reaching effects. One important aspect has been development of a variety of ini-tiatives focused on the generation, endorsement, and reporting of numerous measures related to the safety and quality of health-care—primarily process and outcomes measures. However, the science of measure development is slow paced and, unfortu-nately, has difficulty evolving at the same pace of change as clinical medicine or healthcare delivery systems.Given the strong interest for improved knowledge and information by consumers of healthcare, the trend toward public reporting has rapidly gained momentum and outpaced


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Surgery_Schwartz. or healthcare delivery systems.Given the strong interest for improved knowledge and information by consumers of healthcare, the trend toward public reporting has rapidly gained momentum and outpaced report-ing from the measurement science community. This has sub-sequently created occasional confusion and uncertainty in the marketplace—simply because the generation of public reports are not necessarily always based upon solid scientific data or evidence. The resulting net effect can be creation of a prema-ture focus by organizations and providers on achieving success within influential public reporting venues (e.g., U.S. News Best Hospitals) and uncertainty by patients on what are optimal healthcare information resources.Brunicardi_Ch12_p0397-p0432.indd 41220/02/19 3:57 PM 413QUALITY, PATIENT SAFETY, ASSESSMENTS OF CARE, AND COMPLICATIONSCHAPTER 12Ideally centered on the public good, federal government sponsored healthcare payment plans are also focused upon mea-surement and


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Surgery_Schwartz. PATIENT SAFETY, ASSESSMENTS OF CARE, AND COMPLICATIONSCHAPTER 12Ideally centered on the public good, federal government sponsored healthcare payment plans are also focused upon mea-surement and reporting within the industry. One such initiative funded and overseen by the Agency for Healthcare Research and Quality (AHRQ) is the Hospital Consumer Assessment of Health-care Providers and Systems (HCAHPS) program.51 AHRQ works closely with a consortium of public and private research organi-zations to develop and maintain the HCAHPS surveys, but they do not administer any of the surveys to patients or require use of the surveys. The intent of the HCAHPS initiative is to provide a standardized survey instrument and data collection methodology for measuring patients’ perspectives on hospital care (Fig. 12-7).While many hospitals have collected information on patient satisfaction, prior to HCAHPS there was no national standard for collecting or publicly reporting patients’ perspec-tives of


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Surgery_Schwartz. (Fig. 12-7).While many hospitals have collected information on patient satisfaction, prior to HCAHPS there was no national standard for collecting or publicly reporting patients’ perspec-tives of care information that would enable valid comparisons to be made across all hospitals. Three broad goals have shaped the HCAHPS Survey. First, the survey is designed to produce comparable data on the patient’s perspective on care that allows objective and meaningful comparisons between hospitals on domains that are important to consumers. Second, public report-ing of the survey results is designed to create incentives for hospitals to improve their quality of care. Hospitals frequently distribute the results of HCAHPS surveys of individual ser-vices or physicians to incentivize corrective steps and improve patients’ perceptions of their care. Third, public reporting will serve to enhance public accountability in healthcare by increas-ing the transparency of the quality of hospital care


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Surgery_Schwartz. and improve patients’ perceptions of their care. Third, public reporting will serve to enhance public accountability in healthcare by increas-ing the transparency of the quality of hospital care provided in return for the public investment (www.hcahpsonline.org).HCAHPS scores are now directly tied to a hospital’s CMS reimbursement by federal law, and survey results account for 25% of the value-based purchasing score—directly impacting a hospital’s Medicare payments.52 In May 2005, the National Quality Forum (NQF), an organization established to standard-ize healthcare quality measurement and reporting, formally endorsed the HCAHPS Hospital Survey. The NQF endorsement represents the consensus of many healthcare providers, consumer groups, professional associations, purchasers, federal agencies, and research and quality organizations (www.qualityforum.org).While the American College of Surgeons and other profes-sional societies continue to develop and implement scientifically based


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Surgery_Schwartz. agencies, and research and quality organizations (www.qualityforum.org).While the American College of Surgeons and other profes-sional societies continue to develop and implement scientifically based healthcare measures, the escalating prevalence of less robust measures developed outside of scientific communities will also continue to expand. The patient population, provider organizations, payer organization, and the surgical community will necessarily need to find the balance of developing and uti-lizing valid patient-based information for decision-making.RISK MANAGEMENTBetween one-half to two-thirds of hospital-wide adverse events are attributable to surgical care. Most surgical errors occur in the OR and are technical in nature. Surgical complications and adverse outcomes have previously been linked to lack of surgeon specialization, low hospital volume, communication breakdowns, fatigue, surgical residents and trainees, and numer-ous other factors.53However, poor surgical outcomes


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Surgery_Schwartz. been linked to lack of surgeon specialization, low hospital volume, communication breakdowns, fatigue, surgical residents and trainees, and numer-ous other factors.53However, poor surgical outcomes are not necessarily cor-related with a surgeon’s level of experience in performing a cer-tain procedure. In one study, three-fourths of the technical errors that occurred in a review of malpractice claims data involved fully trained and experienced surgeons operating within their area of expertise, and 84% occurred in routine operations that do not require advanced training. Rather than surgeon expertise, these errors likely occurred due to situations complicated by patient comorbidity, complex anatomy, repeat surgery, or equip-ment problems (Table 12-11). Because these errors occurred during routine operations, previous suggestions to limit the per-formance of high-complexity operations using selective refer-ral, regionalization, or limitation of privileging may not actually be effective


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Surgery_Schwartz. routine operations, previous suggestions to limit the per-formance of high-complexity operations using selective refer-ral, regionalization, or limitation of privileging may not actually be effective in reducing the incidence of technical error among surgical patients.53In any event, although there has been much emphasis on reducing the prevalence of surgical technical errors as a way of improving surgical care, a technical error in the OR may not be the most important indicator of whether a surgeon will be sued by a patient. Recent studies point to the importance of a surgeon’s communication skills in averting malprac-tice litigation. In the American College of Surgeons’ Closed Claims Study, although intraoperative organ injuries occurred in 40% of patients, a surgical technical misadventure was the most deficient component of care in only 12% of patients. In fact, communication and practice pattern violations were the most common deficiency in care for one third of patients in the


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Surgery_Schwartz. was the most deficient component of care in only 12% of patients. In fact, communication and practice pattern violations were the most common deficiency in care for one third of patients in the Closed Claims Study who received the expected standard of surgical care.54The Importance of Communication in Managing RiskThe manner and tone in which a physician communicates is potentially more important to avoiding a malpractice claim than the actual content of the dialogue. For example, a physician relating to a patient in a “negative” manner may trigger litigious feelings when there is a bad result, whereas a physician relating in a “positive” manner may not. Expressions of dominance, in which the voice tone is deep, loud, moderately fast, unaccented, and clearly articulated, may communicate a lack of empathy and understanding for the patient, whereas concern or anxiety in the surgeon’s voice is often positively related to expressing concern and empathy. General and orthopedic surgeons


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Surgery_Schwartz. a lack of empathy and understanding for the patient, whereas concern or anxiety in the surgeon’s voice is often positively related to expressing concern and empathy. General and orthopedic surgeons whose tone of voice was judged to be more dominant were more likely to have been sued than those who sounded less dominant.55When significant medical errors do occur, physicians have an ethical and professional responsibility to immediately dis-close them to patients. Failure to disclose errors to patients undermines public confidence in medicine and can create legal liability related to fraud. Physicians’ fear of litigation represents a major barrier to error disclosure. However, when handled appropriately, immediate disclosure of errors frequently leads to improved patient rapport, improved satisfaction, and fewer malpractice claims.56 In fact, rapport is the most important factor in determining whether a lawsuit is filed against a physician.In 1987, the Department of Veterans Affairs


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Surgery_Schwartz. satisfaction, and fewer malpractice claims.56 In fact, rapport is the most important factor in determining whether a lawsuit is filed against a physician.In 1987, the Department of Veterans Affairs Hospital in Lexington, Kentucky, implemented the nation’s first formal apology and medical error full disclosure program, which called for the hospital and its doctors to work with patients and their families to settle a case. As a result, the hospital improved from having one of the highest malpractice claims totals in the VA system to being ranked among the lowest quartile of a com-parative group of similar hospitals for settlement and litiga-tion costs over a 7-year period. Its average payout in 2005 was $16,000 per settlement vs the national VA average of $98,000 per settlement, and only two lawsuits went to trial during a 9Brunicardi_Ch12_p0397-p0432.indd 41320/02/19 3:57 PM 414BASIC CONSIDERATIONSPART IYOUR CARE FROM DOCTORSDuring this hospital stay, how oftendid doctors treat you


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Surgery_Schwartz. lawsuits went to trial during a 9Brunicardi_Ch12_p0397-p0432.indd 41320/02/19 3:57 PM 414BASIC CONSIDERATIONSPART IYOUR CARE FROM DOCTORSDuring this hospital stay, how oftendid doctors treat you with courtesyand respect?5.NeverSometimesUsuallyAlways1234During this hospital stay, how oftendid doctors listen carefully to you?6.NeverSometimesUsuallyAlways1234During this hospital stay, how oftendid doctors explain things in a wayyou could understand?7.During this hospital stay, how oftenwere your room and bathroom keptclean?8.NeverSometimesUsuallyAlways1234THE HOSPITAL ENVIRONMENTNeverSometimesUsuallyAlways1234During this hospital stay, how oftenwas the area around your room quietat night?9.NeverSometimesUsuallyAlways1234YOUR EXPERIENCES IN THIS HOSPITALDuring this hospital stay, did youneed help from nurses or otherhospital staff in getting to thebathroom or in using a bedpan?10.YesNo If No, Go to Question 1212During this hospital stay, did youhave any pain?12.YesNo If No, Go to


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Surgery_Schwartz. youneed help from nurses or otherhospital staff in getting to thebathroom or in using a bedpan?10.YesNo If No, Go to Question 1212During this hospital stay, did youhave any pain?12.YesNo If No, Go to Question 1512NeverSometimesUsuallyAlways1234How often did you get help in gettingto the bathroom or in using a bedpanas soon as you wanted?11.NeverSometimesUsuallyAlways1234During this hospital stay, how oftendid hospital staff talk with you abouthow much pain you had?13.During this hospital stay, how oftendid hospital staff talk with you abouthow to treat your pain?14.NeverSometimesUsuallyAlways12342January 2018Table 12-11Common causes of lawsuits in surgery• Positional nerve injury• Common bile duct injury• Failure to diagnose or delayed diagnosis• Failure to treat, delayed treatment, or wrong treatment• Inadequate documentation• Inappropriate surgical indication• Failure to call a specialist• Cases resulting in amputation/limb lossFigure 12-7. Survey page from 2018 HCAHPS patient


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Surgery_Schwartz. or wrong treatment• Inadequate documentation• Inappropriate surgical indication• Failure to call a specialist• Cases resulting in amputation/limb lossFigure 12-7. Survey page from 2018 HCAHPS patient questionnaire. (Modified with permission from Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) https://www.hcahpsonline.org/en/survey-instruments/. Accessed October 24, 2018.)10-year period. As a result of the success of this program, the Department of Veteran Affairs expanded the program to all VA hospitals nationwide in October 2005. This model also was rep-licated at the University of Michigan Health System with simi-lar results. Its full-disclosure program cut the number of pending lawsuits by one half and reduced litigation costs per case from $65,000 to $35,000, saving the hospital approximately $2 mil-lion in defense litigation bills each year. In addition, University of Michigan’s doctors, patients, and lawyers are happier with this system. The cultural


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Surgery_Schwartz. saving the hospital approximately $2 mil-lion in defense litigation bills each year. In addition, University of Michigan’s doctors, patients, and lawyers are happier with this system. The cultural shift toward honesty and openness also has led to the improvement of systems and processes to reduce medical errors, especially repeat medical errors.57Brunicardi_Ch12_p0397-p0432.indd 41420/02/19 3:57 PM 415QUALITY, PATIENT SAFETY, ASSESSMENTS OF CARE, AND COMPLICATIONSCHAPTER 12With regard to risk management, the importance of good communication by surgeons and other care providers cannot be overemphasized. Whether alerting other members of the care team about a patient’s needs, openly discussing concerns the patient and/or family might have, or disclosing the cause of a medical error, open communication with all parties involved can reduce anger and mistrust of the medical system; the frequency, morbidity, and mortality of preventable adverse events; and the likelihood of


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Surgery_Schwartz. error, open communication with all parties involved can reduce anger and mistrust of the medical system; the frequency, morbidity, and mortality of preventable adverse events; and the likelihood of litigation.COMPLICATIONSDespite the increased focus on improving patient safety and minimizing medical errors, it is impossible to eliminate human error entirely. Individual errors in judgment or technique can cause minor or major complications during or after a surgical procedure. Although these types of errors may not be quantified as easily as wrong-site surgery or a retained surgical item, they can still lead to surgical complications that prolong the course of illness, lengthen hospital stay, and increase morbidity and mortality rates. In addition to technical and management errors, patient comorbidities also increase the risk of complications. The recognition and management of complications is a critical component of surgical care.Robotic SurgerySurgical advancements would not exist


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Surgery_Schwartz. comorbidities also increase the risk of complications. The recognition and management of complications is a critical component of surgical care.Robotic SurgerySurgical advancements would not exist without intellectual curi-osity, innovation, and technical developments; robotic surgery is a prime example of such an advance. With these advance-ments, however, errors and complications appear to be an inevi-table and recognized risk by institutions and stakeholders due to unforeseen risks inherent in the new technology and the failure or delay of achieving expertise with a new device or technology. Although the reward for adopting new advances may be noto-riety, increased patient referrals, improved patient satisfaction, decreased pain, and possibly decreased length of stay, the risks of adopting new technologies and methods become apparent only after widespread use.Multiple surgical specialties have begun or continue to develop their experiences using robotic surgery from general surgery