PATIENT SAFETY IN SURGERY PROF. PANKAJ G. JANI ASSOCIATE PROFESSOR DEPARTMENT OF SURGERY UNIVERSITY OF NAIROBI

SAFETY IS PARAMOUNT PRIMAM NON NOCERE PRIMAM NON NOCERE FIRST DO NO HARM FIRST DO NO HARM PATIENT SAFETY IS COMPROMISED BY ERRORS PATIENT SAFETY IS COMPROMISED BY ERRORS

ERRORS ERRORS IN HEALTH CARE ARE THE EIGHTH LEADING CAUSE OF DEATH IN THE U.S. AND ACCOUNTS FOR 120,000 DEATHS ANNUALLY

CRISIS IN HEALTH CARE National Safety Council, 1998

ERROR OF EXECUTION  FAILURE OF PLANNED ACTION TO BE COMPLETED AS INTENDED OF EXECUTION  FAILURE OF PLANNED ACTION TO BE COMPLETED AS INTENDED OF PLANNING  USE OF WRONG PLAN TO ACHIEVE AN AIM OF PLANNING  USE OF WRONG PLAN TO ACHIEVE AN AIM

ADVERSE EVENT (COMPLICATION) INJURY CAUSED BY MEDICAL MANAGEMENT OTHER INJURY CAUSED BY MEDICAL MANAGEMENT OTHER THAN THE UNDERLYING CONDITION OF THE PATIENT

ADVERSE EVENT ADVERSE EVENT IF CAUSED BY ERROR(S) – IT IS PREVENTABLE IF CAUSED BY ERROR(S) – IT IS PREVENTABLE 66% OF ALL ADVERSE EVENTS ARE SURGICAL 66% OF ALL ADVERSE EVENTS ARE SURGICAL 50% OF ALL ADVERSE EVENTS ARE PREVENTABLE 50% OF ALL ADVERSE EVENTS ARE PREVENTABLE

PATIENT SAFETY IS THE PRIME DUTY OF THOSE:- ORGANISING} ORGANISING} MANAGING}MEDICAL PRACTICE MANAGING}MEDICAL PRACTICE CONTROLLING } CONTROLLING } THEY MUST PROVIDE THE RIGHT ENVIRONMENT}FOR DOCTORS THE RIGHT ENVIRONMENT}FOR DOCTORS MOTIVATED STAFF}TO TREAT MOTIVATED STAFF}TO TREAT CORRECT EQUIPMENT}PATIENTS CORRECT EQUIPMENT}PATIENTS ADEQUATE SUPPORT}SAFELY ADEQUATE SUPPORT}SAFELY

IN THE DEVELOPED WORLD THE FOREGOING ITEMS ARE AVAILABLE SO TO IMPROVE PATIENT SAFETY, IMPROVEMENT OF “SAFETY CULTURE” IS CONCERNTRATED UPON. IN THE DEVELOPED WORLD THE FOREGOING ITEMS ARE AVAILABLE SO TO IMPROVE PATIENT SAFETY, IMPROVEMENT OF “SAFETY CULTURE” IS CONCERNTRATED UPON. IN DEVELOPING COUNTRIES FAR FROM ABOVE AND A DIFFERENT FORUM NEEDED TO ADDRESS ISSUES OF PROVISION OF SOUND MEDICAL ENVIRONMENT AND THEREFORE I WILL CONCERNTRATE ON LOCAL PROBLEMS TO IMPROVE PATIENT SAFETY IN DEVELOPING COUNTRIES FAR FROM ABOVE AND A DIFFERENT FORUM NEEDED TO ADDRESS ISSUES OF PROVISION OF SOUND MEDICAL ENVIRONMENT AND THEREFORE I WILL CONCERNTRATE ON LOCAL PROBLEMS TO IMPROVE PATIENT SAFETY

RECRUITMENT FOR SURGICAL TRAINING SPECIAL SKILLS REQUIRED COMMUNICATION COMMUNICATION CLINICAL APTITUDE CLINICAL APTITUDE ATTITUDE ATTITUDE MANUAL DEXTERITY MANUAL DEXTERITY PHYSICAL SKILLS } TO SELECT PHYSICAL SKILLS } TO SELECT PSYCHOMETRIC } SURGEONS PSYCHOMETRIC } SURGEONS TESTING } FOR TRAINING TESTING } FOR TRAINING

TO IMPROVE PATIENT SAFETY IN SURGERY IN DEVELOPING COUNTRIES TO IMPROVE PATIENT SAFETY IN SURGERY IN DEVELOPING COUNTRIES A GOOD SURGEON KNOWS WHEN NOT TO OPERATE A GOOD SURGEON KNOWS WHEN NOT TO OPERATE BIG SURGEONS MAKE BIG INCISIONS BIG SURGEONS MAKE BIG INCISIONS USE OF DRAINS USE OF DRAINS USE OF NASOGASTRIC TUBES USE OF NASOGASTRIC TUBES COLON PREPARATION COLON PREPARATION ANTIBIOTICS ANTIBIOTICS

A GOOD SURGEON KNOWS WHEN NOT TO OPERATE INVESTGATIVE FACILITIES LIMITED (C.T., U/S) INVESTGATIVE FACILITIES LIMITED (C.T., U/S) GOOD CLINICAL SKILLS ESSENTIAL GOOD CLINICAL SKILLS ESSENTIAL DEDICATION AND WORK DISCIPLINE REQUIRED (REPEATED FREQUENT EXAMINATIONS) DEDICATION AND WORK DISCIPLINE REQUIRED (REPEATED FREQUENT EXAMINATIONS) BASIC LABORATORY FACILITIES TO BE AVAILABLE BASIC LABORATORY FACILITIES TO BE AVAILABLE

A GOOD SURGEON KNOWS WHEN NOT TO OPERATE CANCER OF THE OESOPHAGUS (95% ADV) CANCER OF THE OESOPHAGUS (95% ADV) CANCER OF THE STOMACH (>90%) CANCER OF THE STOMACH (>90%) CANCER OF THE PANCREAS (>95% ADV) CANCER OF THE PANCREAS (>95% ADV) MANY OPERATED FOR PALLIATIVE CARE AND WITH VERY LITTLE BENEFIT MANY OPERATED FOR PALLIATIVE CARE AND WITH VERY LITTLE BENEFIT NEGATIVE APPENDECTOMY RATES(25%) NEGATIVE APPENDECTOMY RATES(25%) NEGATIVE LAPAROTOMY RATES(PASW) NEGATIVE LAPAROTOMY RATES(PASW) App. (20%) App. (20%)

BIG SURGEONS MAKE BIG INCISIONS TREND FROM LOGITUDINAL INCISIONS TO TRANSVERSE INCISIONS TREND FROM LOGITUDINAL INCISIONS TO TRANSVERSE INCISIONS CAN OPERATE CONFIDENTLY WHEN YOU CAN CAN OPERATE CONFIDENTLY WHEN YOU CAN SEE CLEARLY SEE CLEARLY DELAYED PRESENTATION DELAYED PRESENTATION ADVANCED PATHOLOGY ADVANCED PATHOLOGY ANTOMY DISTORTED ANTOMY DISTORTED

DRAINS ADVANCED PATHOLOGY ADVANCED PATHOLOGY DELAYED TREATMENT  DELAYED TREATMENT  - DISTORTED ANTOMY - DISTORTED ANTOMY  - DIFFICULT DISSECTION - DIFFICULT DISSECTION  MORE POST-OP COLLECTIONS MORE POST-OP COLLECTIONS POOR POST-OP INVESTIGATIVE FACILITIES POOR POST-OP INVESTIGATIVE FACILITIES

NESOGASTRIC TUBES YOUNG PATIENTS YOUNG PATIENTS BENEFIT OUTWEIGHS HARM BENEFIT OUTWEIGHS HARM

COLON PREPARATION LOCAL SERIES REQUIRED BEFORE IT IS GIVEN UP

ANTIBIOTICS SURGERY OF CONTAMINATED AREAS SHOULD BE DISCOURAGED IF APPROPRIATE ANTIBIOTICS NOT AVAILABLE SURGERY OF CONTAMINATED AREAS SHOULD BE DISCOURAGED IF APPROPRIATE ANTIBIOTICS NOT AVAILABLE

SURGERY WITHOUT PROPER RESOURCES IS BAD PRACTICE, POTENTIALLY DANGEROUS AND UNACCEPTABLE SURGERY WITHOUT PROPER RESOURCES IS BAD PRACTICE, POTENTIALLY DANGEROUS AND UNACCEPTABLE