Patient safety

Selected bibliography supporting the ten essential objectives for safe surgery

10. Hospitals and public health systems will establish routine surveillance of surgical capacity, volume, and results.

Berwick, D. M. (1989). "Continuous improvement as an ideal in health care." N Engl J Med 320(1): 53-6.

Berwick, D. M. (2003). "Disseminating innovations in health care." Jama 289(15): 1969-75.

  • Health care is rich in evidence-based innovations, yet even when such innovations are implemented successfully in one location, they often disseminate slowly-if at all. Diffusion of innovations is a major challenge in all industries including health care. This article examines the theory and research on the dissemination of innovations and suggests applications of that theory to health care. It explores in detail 3 clusters of influence on the rate of diffusion of innovations within an organization: the perceptions of the innovation, the characteristics of the individuals who may adopt the change, and contextual and managerial factors within the organization. This theory makes plausible at least 7 recommendations for health care executives who want to accelerate the rate of diffusion of innovations within their organizations: find sound innovations, find and support "innovators," invest in "early adopters," make early adopter activity observable, trust and enable reinvention, create slack for change, and lead by example.

Berwick, D. M. (2008). "The science of improvement." Jama 299(10): 1182-4.

Berwick, D. M., D. R. Calkins, et al. (2006). "The 100,000 lives campaign: setting a goal and a deadline for improving health care quality." Jama 295(3): 324-7.

Burke, J. P. (2003). "Infection control - a problem for patient safety." N Engl J Med 348(7): 651-6.

Donabedian, A. (1966). "Evaluating the Quality of Medical Care." Milbank Memorial Fund Quarterly 44:: 166—203.

Donabedian, A. (1988). "The quality of care: how can it be assessed?" JAMA 260(12): 1743-1748.

  • Before assessment can begin we must decide how quality is to be defined and that depends on whether one assesses only the performance of practitioners or also the contributions of patients and of the health care system; on how broadly health and responsibility for health are defined; on whether the maximally effective or optimally effective care is sought; and on whether individual or social preferences define the optimum. We also need detailed information about the causal linkages among the structural attributes of the settings in which care occurs, the processes of care, and the outcomes of care. Specifiying the components or outcomes of care to be sampled, formulating the appropriate critieria and standards, and obtaining the necessary information are the steps that follow. Though we know much about assessing quality, much remains to be known.

Gawande, A. A., M. R. Kwaan, et al. (2007). "An Apgar score for surgery." J Am Coll Surg 204(2): 201-8.

  • BACKGROUND: Surgical teams have not had a routine, reliable measure of patient condition at the end of an operation. We aimed to develop an Apgar score for the field of surgery, an outcomes score that teams could calculate at the end of any general or vascular surgical procedure to accurately grade a patient's condition and chances of major complications or death.
  • STUDY DESIGN: We derived our surgical score in a retrospective analysis of data from medical records and the National Surgical Quality Improvement Program for 303 randomly selected patients undergoing colectomy at Brigham and Women's Hospital, Boston. The primary outcomes measure was incidence of major complication or death within 30 days of operation. We validated the score in two prospective, randomly selected cohorts: 102 colectomy patients and 767 patients undergoing general or vascular operations at the same institution.
  • RESULTS: A 10-point score based on a patient's estimated amount of blood loss, lowest heart rate, and lowest mean arterial pressure during general or vascular operations was significantly associated with major complications or death within 30 days (p < 0.0001; c-index = 0.72). Of 767 general and vascular surgery patients, 29 (3.8%) had a surgical score
  • CONCLUSIONS: A simple score based on blood loss, heart rate, and blood pressure can be useful in rating the condition of patients after general or vascular operations.

Health Metrics Network (2006). Framework and standards for the development of country health information systems, World Health Organisation.

Regenbogen, S. E., R. T. Lancaster, et al. (2008). "Does the Surgical Apgar Score measure intraoperative performance?" Ann Surg (in press).

Ronsmans, C. and W. J. Graham (2006). "Maternal mortality: who, when, where, and why." Lancet 368(9542): 1189-200.

  • BACKGROUND: Anaesthetists may experience difficulty with intubation unexpectedly which may be associated with difficulty in ventilating the patient. If not well managed, there may be serious consequences for the patient. A simple structured approach to this problem was developed to assist the anaesthetist in this difficult situation.
  • OBJECTIVES: To examine the role of a specific sub-algorithm for the management of difficult intubation.
  • METHODS: The potential performance of a structured approach developed by review of the literature and analysis of each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved.
  • RESULTS: There were 147 reports of difficult intubation capable of analysis among the first 4000 incidents reported to AIMS. The difficulty was unexpected in 52% of cases; major physiological changes occurred in 37% of these cases. Saturation fell below 90% in 22% of cases, oesophageal intubation was reported in 19%, and an emergency transtracheal airway was required in 4% of cases. Obesity and limited neck mobility and mouth opening were the most common anatomical contributing factors.
  • CONCLUSION: The data confirm previously reported failures to predict difficult intubation with existing preoperative clinical tests and suggest an ongoing need to teach a pre-learned strategy to deal with difficult intubation and any associated problem with ventilation. An easy-to-follow structured approach to these problems is outlined. It is recommended that skilled assistance be obtained (preferably another anaesthetist) when difficulty is expected or the patient's cardiorespiratory reserve is low. Patients should be assessed postoperatively to exclude any sequelae and to inform them of the difficulties encountered. These should be clearly documented and appropriate steps taken to warn future anaesthetists.

Weiser, T., S. Regenbogen, et al. "An estimation of the global volume of surgery." (submitted).