predictive value of surgical safety checklist and operating room (or) briefings in dentistry

Dr.Shoeb and Dr.Irfana (2011): The predictive value of surgical safety checklist and operating Room (OR)briefings in Dentistry. DATE- 30-03-2011

Predictive Value of Surgical Safety Checklist and Operating Room (OR) briefings in

Dentistry.

Author: Dr. Shoeb Ahmed Ilyas BDS, MPH, EMSRHS, M.Phil. (HHSM), MHRM, MS (PSY), MS

(BIOTECH), PGDMLE, FHTA.

Health Care Quality Management Consultant

Ruby Med Plus, Telangana State, India.

Health care is complex, with several interdisciplinary elements, incredibly unpredictable and at

high risk of hazard. Healthcare environments are complex and tightly coupled systems that have

proven to be error-pronei. Patients expect to be reasonably safe when under medical

supervisionii. In 1999, the US based, Institute of Medicine report, To Err is Human, claimed that

between 44.000 and 98.000 patients in the US die every year from preventable adverse events.

However regardless of an ongoing push for drastic improvement of the safety culture in

healthcare, medical errors continue to occur at unacceptable ratesiii

.

The rising cost of health care is given progressively more importance worldwide. A major factor

affecting hospital cost is complications following surgeryiv

. Surgical care is an integral part of

health care throughout the world, with an estimated 234 million operations performed annuallyv.

Surgical complications are a considerable cause of death and disability around the world. The

World Bank reported that in 2002, an estimated 164 million disability-adjusted life years,

representing 11% of the entire disease burden, were attributable to surgically treatable


conditionsvi

. Surgical complications are devastating to patients, costly to health care systems, and

often preventable, though their prevention typically requires a change in systems and individual

behavior.

Safety is a critical aspect of the quality of care in a complex hospital setting. Wrong-site, wrong-

procedure and wrong patient surgeries are catastrophic events for patients, medical caregivers

and institutionsvii

. Given that complications are, in general, associated with increased length of

stay and cost, it is possible that such a reduction in morbidity rate will generate cost savings that

can offset the expense of prospective data collectionviii

. Data suggest that at least half of all

surgical complications are avoidableix

. Previous efforts to implement practices designed to

reduce surgical site infections or anesthesia-related mishaps have been shown to reduce

complications significantlyx.

The Rationale of Surgical Safety Checklist in Health care-

Documented variation in the quality of medical care, especially for surgical procedures, has led

to enthusiasm for systematic quality improvement programsxi

.With extensive implementation;

such systems might potentially reduce morbidity and mortality across big groups of Health care

providers. In 2004, The Joint Commission introduced the mandatory Universal Protocol to all

accredited hospitals as a means of preventing wrong surgeries or surgeries on the wrong patient

or wrong site—sentinel events that have proven to be a direct result of communication failuresxii

.

In 2008, the World Health Organization (WHO) published guidelines identifying multiple

recommended practices to ensure the safety of surgical patients worldwide. The Safe Surgery

Saves Lives Study Group at the World Health Organization (WHO) published the results of

instituting a perioperative surgical safety checklistxiii

. The use of this checklist in eight hospitals

around the world was associated with a reduction in major complications from 11.0% before

introduction of the checklist to 7.0% afterward.


Figure- 1 shows WHO Surgical safety checklist.

The results of a global pilot of the WHO checklistxiv

, demonstrated reliable performance

Of a series of safety checks, this could reduce surgical mortality and morbidity. Most

Commonly reported benefits of implementing the checklist were improved teamwork, safety,

more near misses captured smoother / quicker procedures and improved staff morale. The

two most commonly reported challenges for implementation of safety checklist are lack of

Clinical engagement, and a tendency to see the Checklist as a ‘tick box exercise’, rather than as a

tool to enhance communication and teamwork, hence adoption of safety checklist requires

Changes in systems and behavior of individual surgical teams.


The Operating Room (Operating Room (OR)) briefings improves Surgical Outcomes -

The purpose of the Operating Room (Operating Room (OR)) briefings is to formulate and share

the operative plan, to promote teamwork, to alleviate hazards to patients, to reduce preventable

harm, and to ensure all required equipment is available. The Operating Room (OR) briefing

checklist, named as Operating Room (OR) Briefing 5, enhances communication among

Operating Room (OR) team members and improve patient safety (Table-1). The 2-minute

Operating Room (OR) briefing familiarizes surgical team with each other and with the operative

plan through 3 critical components:

1. Each member of the Operating Room (OR) team states his or her name and role;

2. The surgeon leads the “timeout” to identify critical components of the operation,

including the surgical site.

3. Surgical care teams discuss and mitigate potential safety hazardsxv

.

What are the names and roles of the team members?

Is the correct patient/procedure confirmed? (TIME-OUT)

Have antibiotics been given? (if appropriate)

What are the critical steps of the procedure?

What are the potential problems for the case?

Reviewed by nursing, anesthesia, and surgery.

Table- 1 showing Operating Room Briefing 5.

The philosophy of ensuring the correct identity of the patient and site through preoperative site

marking, oral confirmation in the operating room, and other measures proved better surgical

outcomes and reduced cost of surgical complications. A “surgical time-out” or “surgical pause,”

introduced on 1st June, 2006, involves the Operating Room (OR) team convening after the

administration of anesthetic but before skin incision for each patient to reverify the patient,

procedure and site of surgery.


Figure- 2 shows 5 steps for safer surgery (Adapted from Patient Safety First)

The Hospital for Sick Children (Sick Kids) in Toronto, Ont., initiated two Operating Room

safety initiatives: a “07:35 huddle” (preoperative Operating Room (OR) briefing) and a “surgical

time-out” (perioperative Operating Room (OR) briefing).

The above tools provide Operating Room (OR) teams with a structured and standardized

approach to increase interdisciplinary communication in the Operating Room (OR), thereby

promoting teamwork and creating a culture of safety. The expectation is that Operating Room

(OR) team members are encouraged to become more proactive about patient safety, speak up

when an identified problem in patient care is discovered and improve patient outcomes.ii

In all

Dental Operating Room (OR)s there must be 1-page laminated poster highlighting the key

components of huddles and time-outs to facilitate and guide the Dental Operating Room (OR)

briefings. Exposing Dental students, interns and residents to safety initiatives and incorporating

such initiatives into Dental educational curricula may encourage positive shift in the culture of

Operating Room and it may serve to get more future Dental Surgeons “to believe in the

importance of surgical safetylist and operative briefings rather than go through the motions.”

Conclusion –

The use of surgical safety checklist and Operating Room (OR) briefings as a routine procedure

helps to reduce preventable Dental surgical risks. Dental Hospitals should consider implementing


Safety Checklists and Operating Room (OR) briefings as a strategy to improve efficiency,

clinical and economic outcomes in Dental patients. Applied on a global basis, surgical safety

checklist and Operating Room (OR) briefings has the potential to prevent large numbers of

dental surgery complications, although further studies are needed to determine the precise

mechanism and durability of the effects of surgical safety list and Dental Operating Room

briefings in Dental Hospitals.

References - i Kohn LT, Corrigan JM, Donaldson MS.To Err is Human: Building a Safer Health System.

Washington, DC: National Academy Press; 2000.

ii DeFontes J, Surbida S. Preoperative safety briefing project. Permanente J. 2003; 8(2):21-27.

iii

Awad SS, Fagan SP, Bellows C, et al. Bridging the communication gap in the OR with

medical team training. Am J Surg. 2005; 190:770-774.

iv

Mason L, Garcia A. Hospital costs of surgical complications. Arch Surg.1984;119:1065–1066.

v Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of

surgery: a modelling strategy based on available data. Lancet 2008;372: 139-44.

vi

Debas HT, Gosselin R, McCord C, Thind A. Surgery. In: Jamison DT, Breman JG, Measham

AR, et al., eds. Disease control priorities in developing countries. 2nd ed. Disease Control

Priorities Project. Washington, DC: International Bank for Reconstruction and

development/World Bank, 2006:1245-60.

vii

Makary MA, Sexton JB, Freischlag JA, et al. Operating room teamwork among physicians and

nurses: teamwork in the eye of the beholder. J Am Coll Surg 2006;202:746-52.

viii

Dimick JB, Pronovost PJ, Cowan JA, Lipsett PA. Complications and costs after high-risk

surgery: where should we focus quality improvement initiatives? J Am Coll Surg 2003;196:

671–678.

ix

Thomas EJ, Zinner MJ, Brennan TA. The incidence and nature of surgical adverse events in

Colorado and Utah in 1992. Surgery 1999;126:66-75.

x Dellinger EP, Hausmann SM, Bratzler DW, et al. Hospitals collaborate to decrease surgical site

infections. Am J Surg 2005;190:9-15.


xi

Chassin M, Galvin RW. The urgent need to improve health care quality. Institute of Medicine

national roundtable on health care quality. JAMA 1998;280:1000–1005.

xii

The Joint Commission. Universal protocol for preventing wrong site, wrong procedure, wrong

person surgery. http:// www.jointcommission.org/Patient Safety/UniversalProtocol.

xiii

Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and

mortality in a global population. N Engl J Med 2009;360:491-9.

xiv

. The New England Journal of Medicine, 360, p491, January 2009, ‘A Surgical Safety

Checklist to Reduce Morbidity and Mortality in a Global Population.

xv

Makary MA, Holzmueller CG, Thompson D, et al. Operating room briefings: working on the

same page. Jt Comm J Qual Patient Saf. 2006;32(6):351-355.

http://www.jointcommission.org/Patient