Safety and Surgical Checklists

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Presentation transcript:

Safety and Surgical Checklists

Goals and Objectives Care of Neurosurgical Patient Pre, Intra, and Post-Operative Checklists Validated Tools in the Neurosurgical Setting Environments particular to Neurosurgery Neuromonitoring Intra-Operative MRI Sub-specialty Specific Considerations for Process Quality

Surgical Checklists Surgical Time Out (WHO and JCAHO) Components Prospective Data on 7688 surgical patients Death 1.5% to 0.8%; Complications 11% to 7% Components Correct Patient, Procedure, and Surgical Site Specialty Specific Checklists Adverse Event Division of Labor Intra-Procedural Aneurysm Rupture

Checklist Practice Challenges UCLA Prospective Experience Cultural Change: Who leads surgical pause? Practice Change: 3-5 minute completion Standardization of Time Out Potential for Smart Tailored Checklists

Culture of Safety Reporting Sources of Errors: Communication Multidisciplinary Team Provider Roles in Timeout and Checklists Berger et al. Safety Reporting Video

Aviation Incidence Guide Human Factor Analysis Track, Analyze, Categorize Near Misses Severity and Duration Ferroli et al. (14 near misses) Human Factors (9/14) Technology (1/14) Organizational Factors (3/14) Procedural Factors (1/14)

Near Miss Factor Analysis Human Factors Omission, Lack of Communication, Late Detection Multitasking, Teamwork Failure, Time Pressure Technologies Equipment Allocation, Instruments, Interface, Data Interpretation Organizational Factors task allocation/overlap Procedural Factors (checklist effectiveness)

Surgical Debriefing Systems Based Practice Real-Time Quality Feedback Diversity of Team Member Perspective

Patterns of Adverse Events in Neurosurgery Surgical Technique Perioperative medical management Protocol Use and Adherence Pre-Operative Optimization Technology Communication

Solutions Process and Outcomes Monitoring Regionalization and Subspecialization Guidelines and Protocols Equipment Standardization Surgical Checklists

Sub-Specialty Considerations Spine Intra-Operative Neurophysiological Monitoring Endovascular Intra-Operative MRI