Improving Patient Safety in the Dutch OR’s

Johan LangeDepartment of Surgery Erasmus University Medical Center Rotterdam

Historical development crtitical success factors in surgery

0 21st century

instruments&apparatus

Professional training

medication(anesthetics, AB, heparin)

Risk factors patient

Best practices, protocols(patientsafety)

factor Results

Patient safety in the Netherlands (reports)

To err is human (Institute of Medicine 1999)

Hier werk je veilig, of je werkt hier niet (VMS; Rein Willems 2004)

TOP I (toezicht preoperatief proces/registratie; IGZ 2007)

Het resultaat telt (prestatieindicatoren IGZ)

Uitgeteld? (Meijsen, Meers 2007) Voorkom schade, werk veilig (OMS,

NVZ, LEVV 2007) Koers op kwaliteit (VWS 2007) TOP II (toezicht peroperatief

proces/registratie; IGZ 2008) Adviesrapport Cie Patiëntveiligheid

NVvH

Adverse events in the Dutch OR (2005)

45000 adverse events in 1.000.000 operations/year (all specialisms)

25000 adverse events in surgery: 2.5% of operations 10.000 adverse events in surgery: avoidable Probably only 25% is reported 400 mortal adverse events in the OR 130 mortal adverse events in surgery 40%: avoidable: 50 avoidable death in surgery/year

-Report ‘Onbedoelde schade in de Nederlandse ziekenhuizen (Emgo/NIVEL 2007)

-Cuperus-Bosma JM et al. NTvG 2005; 149: 2153-6

Adverse events in surgery

36% of all adverse events in health care

Avoidable: 40%

>50%: related to the individual surgeon

Tenerife 1977: 583 death

Aviation before 1977: autocratic leadership

=

Incidents in aviation: ‘75% (human factors)-rule’

accident-analysis, blackbox, simulator-research:

‘75% rule’: 75% of incidentscaused by teamwork-failure

(human factors, chain of errors,

human performance limitation)

Teamwork: shared mental model

Team situational awareness by:

Sharing knowledge:

Goals

Tasks

Responabilities Free flow of information among

crew menbers, without fear of reservation (beware of dependance and hierarchy)

CRM (Crew Resource Management)

• Obligation: Joint Aviation Requirements

• Coaching instead of autocratic leadership

• Leader-follower roles

• Cross checking (briefing/debriefing, checklists)

• Intervision/peer assessment (blame free-reporting)

CRM: technically-complex high risk industries

OR 21st century: technically-complex high risk environment

Report ‘To err is human’Institute of Medicine USA 1999

"The experiences of other industries provide valuable insight about how to begin the process of improving safety of health care by learning how to prevent, detect, recover and learn from accidents."

VWS-Report ‘Here you are working safely, or you do not work here at all’‘The safety of Care’ 2004

Recommendations:

1) Safety management system in all hospitals (VMS)

Blamefree incident-reporting

VWS-Report ‘Here you are working safely, or you do not work here at all’‘The safety of Care’ 2004Rein Willems (CEO Shell) Recommendations:

1) Safety management system in all hospitals (VMS)

Blamefree incident-reporting

Teamwork in the OR

OR nurses are dissatisfied with communication in the OR

Nestel D, Kidd J. BMC Nursing 2006; 5:1

Feeling like a team member: 75% of surgeons 53% of residents 45% of anesthesiologists 23% of OR-nurses

team or….

Ongoing taboos in the OR

Failability of the surgeon Horizontal communication Mistakes (Culture of Name

, Blame and Shame)

Communication: conflicts

• Conflict between doctors: in 50% of hospitals

• Conflicts with or within other professions: 36%

Source: L.A.P. Arends, i-BMG Erasmus University 2004

Nijmegen

Utrecht

Meppel

Emmeloord/Lelystad

Autocratic leadership with vertical communication

Ego’s & culture: idolatry

CRM: new leadership in the OR-team

Open communication Coaching/Bindend/Sharing Applying protocols and

S.O.P.’s Blamefree reporting

Professor Rhona Flin (Aberdeen)Behavioural marker observation system for teamwork

Advantages teambuilding/CRM (non technical-skills)

Respect and trust Horizontal communication Sharing knowledge and

targets Coaching/binding/sharing

leadership Cross checking (protocols,

S.O.P.’s) Peer assessment Culture of transparancy

(blamefree reporting) Improved climate

Teamperformance: CRM + expertise (scenario-based simulation)

Teamperformance: CRM + expertise (scenario-based simulation)

Joint Commission on Accreditation of Healtcare Organizations (JCAHO) Universal Protocol for eliminating wrong site-, wrong procedure-, wrong person-surgery

Time Out-Procedure Right side surgery Type of procedure (protocol) Identification patient

Wrong side-surgery

Eye-hospital Rotterdam :disappearance of wrong-side surgery

0123456789

2002 2003 2004

jaar

aant

al bijna fout

fout

TOP (Time Out Procedure)+

Johan Lange, Linda Wauben, Conny Dekker, Geert Kazemier, Jan Klein, Jeroen PetersDepartments of Anesthesiology and Surgery Erasmus MC

Results pilot TOP+

Duration 1-2’ Compliance high In 15% of operations incidents

can be avoided

Anesthiology assistant: director

Time Out=double check

Time-Out

SURPASS (SURgical PAtient Safety System) –perioperative checklist

Validated (Marja Boermeester) Transfermoments (ward-holding-

OR) Stopping rules

Teamwork (CRM): culture shock/paradigma shift

Transforming individual professionals into a professional team

Changing training/medical education

New shared responsabilities New professional relationships

Soft??

Medical eduction/training: teamfunctioning

Patient safety in the OR: planning

Short term-vision: Bureaucracy-reflex model

Regulations Audit

Long term-vision

Regulations Audit Transparance Teamconcept

Historical development crtitical success factors in surgery

0 21st century

instruments&apparatus

Professional training

medication(anesthetics, AB, heparin)

Risk factors patient

Best practices, protocols(patientsafety)

factor Results

Historical development crtitical success factors in surgery

0 21st century

instruments&apparatus

Professional training

medication(anesthetics, AB, heparin)

Risk factors patient

Best practices, protocols(patientsafety)

factor ResultsTeamwork!