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Safe Surgery Saves Lives
Your Organization Your Name Insert Your Logo Here
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Example: aviation tragedy
Safety Stories Example: aviation tragedy Korean Airlines Cockpit culture stopped the first officer [from alerting the pilot to asserting and arguing] about the imminent danger Suggestions and clues are not clear messages An example from your organization where the lack of communication was a risk for patient safety? Close Calls? Actual Adverse Event?
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Surgical Safety is a Serious Issue
Canadian Adverse Events Study (Baker et al. 2004) More than 50% of adverse events involved surgery The Healthcare Insurance Reciprocal of Canada reports that since inception (20 years, with most claims occurring in the last 7-8 years) Surgical claims account for $27 Million, 40% could have been prevented with the checklist or approximately $10 Million Claim types: 210 retained foreign body; 94 wrong body part; 9 wrong patient Add local data Imagine you and your family are going on a roadtrip: with and without a checklist
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WHO Safe Surgery Saves Lives Meeting Geneva
Would the surgery be safer if we would have pictures like those on the hallway to the OR?
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The Faces of Harm Do you remember the face of someone who got hurt?
As we all know the healthcare providers involved in an adverse event are also traumatized. The pain goes both ways.
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Evidence that checklist works
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The Checklist and Communication
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The Canadian Surgical Safety Checklist
A suggested starting point for patients safety Adapted from WHO By Canadian experts Including aviation and human factors professionals Includes elements of other patient safety initiatives Safer healthcare now! VTE and surgical site infection Time-out Hospitals are encouraged to further adapt it to fit their current procedures On the Safe Surgery Community of Practice (link from there are a few versions of the checklist used in Canada by different hospitals. More about the checklist, how to adapt it and resources on
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What issues does this checklist address?
All important safety elements are reviewed for all patients all the time Correct patient, operation and operative site Safe Anaesthesia and Resuscitation Minimize the risk of infection Effective Teamwork Communication is a root cause of nearly 70% of the events reported to the Joint Commission from Preparedness for the unexpected Anyone in the team can speak up if patient safety is at risk
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Doors closed? Checked! Door closed? Check!
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The eight original pilot sites
EURO EMRO PAHO I London, UK Amman, Jordan Toronto, Canada WPRO I Manila, Philippines PAHO II Seattle, USA WPRO II Auckland, NZ AFRO Ifakara, Tanzania SEARO New Delhi, India
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Impact at the pilot sites
~ 8000 operations Morbidity Mortality 11% %* (p<.001) 1.5% %* (p<.003) (actual 4% reduction) (actual 0.7% reduction) 3.2%* HIC (P<.001) 4.9%* LIC P<.001 0.3% HIC ns 1.1%* LIC P<.006 HIC = High Income Countries; LIC = Low Income Countries
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Findings published on January 2009
Link to the full article:
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Strengths of the Surgical Safety Checklist
Customizable to your setting and needs Deployable in an incremental fashion Supported by scientific evidence and expert consensus Evaluated in diverse settings around the world Ensures adherence to established safety practices Minimal resources required to implement a far- reaching safety intervention
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“The estimate that up to 23,000 people died in 2004
The View from Aviation “The estimate that up to 23,000 people died in 2004 in Canadian hospitals because of preventable adverse events is staggering. Checklists have been used in aviation to standardize and increase the reliability of systems. One wonders whether such checklists would have been introduced much earlier in medicine if surgeons shared the fate of their patients, as pilots share that of their passengers.” Adrian Boelen, retired pilot, Dorval, Que
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The Checklist in Canada
Endorsed by professional groups CMA, CAN, CAS, ORNAC, RCPSC downloads of the checklist 150 participants at the March workshop 500 + implementation kits delivered in one week Continuous spread To most provinces and territories To other surgical disciplines Endoscopy, OB, pediatrics, emergency … Urban and rural hospitals Some organizations and provinces aspire to making the Checklist a standard operating procedure
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Why should your hospital adopt it?
Significant commitment needed, but … Insignificant costs to implement yet there is clear evidence of improved safety Issues and omissions are being picked up! It is adaptable and flexible! It is yours! Takes 2-3 minutes but can save time over the course of a day A great team-building opportunity! You will be a leader in patient safety in Canada and the world You only need: Ongoing vigilance A champion (or better, champions) at all levels! Data collection (a method to understand how safety is improving) Commitment from senior management and the board See the “How To” guide for tips in managing the change
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Canadian Patient Safety Institute
Mandate of the in-country Working Group: Lead further development, adaptation, and support for the Safe Surgery Saves Lives Campaign within the Canadian context Goals: Patients: reduced surgical complications and deaths Providers: provide highest quality of care Collaborate with national and international organizations to bring you the best resources Design tools and resources to assist organizations and OR teams in all implementation stages Website
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What can you do to get ready?
Endorse the checklist Read the fact sheet and news release Watch with your team How-to and how not-to do it videos Presentations: Atul Gwande, Bryce Taylor Download the checklist (4 versions Microsoft Word format) Review references Get ready Implement Sustain Available at:
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How to prepare for implementation
Review the implementation kit How: how-to guide What: detailed explanation Why: info, rationale, and FAQ Follow the adaptation guideline (human factors) List your organization on the surgical safety map Communicate with peers on the Safe Surgery Community of practice Get ready Implement Sustain All those resources are available at Available at:
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How to sustain the change
Get ready Participate in “virtual grand rounds” Become a mentor/coach Ask questions Collaborate with others Share successes and barriers Let us know of your successes and concerns! We are learning too! Implement Sustain Contact person: Ioana Popescu: phone: Available at:
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Patient involvement – bad timing!
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Your turn
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