Safe surgery safe life About SSSL Presentation.ppt

Safe surgery safe life

1. Safe Surgery Saves Lives
Your Organization
Your Name
Insert
Your
Logo
Here

2. 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?

3. 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

4. WHO Safe Surgery Saves Lives Meeting Geneva

5. The Faces of Harm

6. Evidence that checklist works

7. The Checklist and Communication

8. The Canadian Surgical Safety Checklist
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
A suggested starting point
for patients safety

9. 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 1995-2005.
•Preparedness for the unexpected
•Anyone in the team can speak up if patient safety is at
risk

10. Doors closed? Checked!

11. London, UK
EURO EMRO
WPRO I
SEARO
AFRO
PAHO I
Amman, Jordan
Toronto, Canada
New Delhi, India
Manila, Philippines
Ifakara, Tanzania
WPRO II
Auckland, NZ
PAHO II
Seattle, USA
The eight original pilot sites

12. ~ 8000 operations
Morbidity Mortality
11% 7%* (p<.001) 1.5% 0.8%* (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
Impact at the pilot sites
HIC = High Income Countries; LIC = Low Income Countries

13. Findings published on January 2009

14. 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 resourcesMinimal resources required to implement a far-
reaching safety intervention

15. “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
The View from Aviation

16. The Checklist in Canada
•Endorsed by professional groups
–CMA, CAN, CAS, ORNAC, RCPSC
•1000 + 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

17. 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

18. 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 www.safesurgerysaveslives.ca

19. 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
Available at: www.safesurgerysaveslives.ca

20. 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
S
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Available at: www.safesurgerysaveslives.ca

21. How to sustain the change
•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!
I
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Available at: www.safesurgerysaveslives.ca

22. Patient involvement – bad timing!

23. Your turn