PATIENT SAFETY The WHO Surgical Safety Checklist

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PAT I E N T S A F E T Y The WHO Surgical Safety Checklist Surgeons and hospitals should show great concern in improving patient safety as adverse events in surgery can be catastrophic for patients, doctors, institutions and caregivers. The medico-legal problems surrounding an adverse event are also an area of major concern for surgeons and institutions. Patient safety in surgery has recently been recognised as a very important public health issue. Using a mathematical model, Weiser et al (2008) estimated that 234 million surgical procedures are done annually in the world. Using the USA data of a mortality rate of 0.4-0.8% deaths and a complication rate of 3-16% it was estimated that 1 million deaths and 7 million disabling complications occur each year worldwide from surgery. The figure below shows the significance of these figures in relation to other public health issues. Figure 1: Global statistics of public health concerns (Courtesy of AB Haynes 2)

THE WORLD ALLIANCE FOR PATIENT SAFETY – SAVE SURGERY SAVES LIVES In 2002, the 55th World Health Assembly adopted a resolution urging countries to strengthen healthcare safety and monitoring systems. In May 2004, the 57th World Health Assembly approved the creation of an international alliance to improve patient safety as a global initiative and this resulted in the formation of the World Alliance for Patient Safety in October 2004. The World Health Organisation (WHO) has recently recognised patient safety in surgery as a major public health issue. In order to create a public health impact, the WHO recognised that its proposed initiatives should be simple, applicable in all countries and settings and were measurable. This resulted in the Second Global Patient Safety Challenge of WHO entitled SAVE SURGERY SAVES LIVES which was initiated in January 2007 by the World Alliance for Patient Safety. Four working groups were created to look into the problem. These four working groups were on safe anaesthesia, infection control, safe surgical teams and measurement of surgical vital statistics. These efforts resulted in three final products, namely, the WHO Surgical Safety Checklist, the WHO Guidelines for Safe Surgery and Surgical Vital statistics. The WHO Surgical Safety Checklist was launched in Washington, DC on 25th June 2008. I am pleased to say that the College of Surgeons, Academy of Medicine of Malaysia was among the organisations which endorsed the checklist.

WHO SURGICAL SAFETY CHECKLIST The WHO Surgical Safety Checklist is illustrated as Fig 2. continued on page 2

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Advanced Trauma Life Support Course For Doctors – ATLS Educator Required College of Surgeons, Academy of Medicine of Malaysia – Annual Scientific Meeting & AGM 2009

Figure 2: THE WHO SURGICAL SAFETY CHECKLIST

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The concepts of safety captured in the WHO Surgical Safety Checklist include the following: • Measures to ensure safe Anaesthesia • Avoiding Wrong Site Surgery – correct patient, correct procedure, correct site • Enhancing effective team communication and exchange of critical information for the safe conduct of the operation • Enhancing operating room (OR) teamwork with OR briefings and debriefing • Avoid inducing an allergic or adverse drug reaction • Preparation for risk of excessive blood loss – intravenous access, blood loss estimation • Reducing the risk of surgical site infections • Prevention of retained instruments or sponges • Correct identification of specimens – avoid subsequent wrong site surgery The time-out or 'surgical pause' in the WHO Surgical Check List is a brief pause (lasting 1-2 minutes) in the operating room immediately prior to incision, at which time all members of the operating team – surgeons, anaesthetists, nurses and anyone else involved in the theatre verbally confirm the identity of the patient, the operative site and the procedure to be performed. This is a safety measure to ensure that the correct patient has the right operation and that the theatre sister knows that the correct instruments are available for the operation. Open communication is encouraged so that any unusual factors about the patient can be discussed. Makary et al 3 found a relationship between briefings/ introductions and safety attitudes and this is probably due to better communication and teamwork between members of the team.

HOW EFFECTIVE IS THE WHO SURGICAL SAFETY CHECKLIST? (Haynes AB, 2008 2) A worldwide multicentre cohort pilot study was done by the Harvard School of Public Heath on behalf of WHO to evaluate the effectiveness of the WHO Surgical Safety Checklist. Countries selected were from developed and developing countries. Data was collected before and after implementation of the Checklist. It is clear from the data below that patient safety is enhanced when the WHO Surgical Safety Checklist is used routinely in hospitals. B A S E L I N E R E S U LT S Cases: 3435 Inpatient Complication: 10.7% Inpatient Death: 1.4% Compliance with safety requirements of checklist • Objective Airway Evaluation 66% • Two IV canulas inserted into patient for Excessive Blood Loss>500mL 45% • Use of Pulse Oximetry 96% • Verbal Confirmation of Patient and Procedure in Operating Room 63% • Antibiotics Given 0-60mins Before Incision 56% • Sponge Counts Performed 85% • All 6 Indicator Processes Performed 33% A F T E R I M P L E M E N TAT I O N O F C H E C K L I S T • •

Preliminary results from first thousand patients with checklist show doubling of adherence to safety measures (to 68%) Substantial decreases in deaths and complications (>25% reduction)

SURVEY OF OPINIONS OF CLINICIANS AT PILOT SITES (Haynes AB, 2008 2) It is interesting to note the opinions of clinicians who participated in the pilot study. • 79% thought it easy to use • 79% thought it improved care • 18% thought it took a long time • 84% thought it improved communication • 78% thought it reduced errors • 93% would want a checklist used if they were having surgery The results show wide acceptance of the checklist. I think the most important finding was that 93% of the clinicians wanted the checklist used if they were having surgery. continued on page 4

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SURGICAL VITAL STATISTICS The WHO also suggested that all Governments and hospitals should from henceforth collect data relevant to surgery. The following are the Surgical Vital Statistics identified by the WHO as important for countries to collect in order to have objective measurements of quality and safety of surgery in its member nations: Number of operating theatres per 100,000 population Number of surgeons and anesthesia professionals per 100,000 population Number of surgical procedures performed in the operating theatre per 100,000 population per year Day-of-surgery mortality rate Postoperative in-patient mortality rate

SUMMARY As surgeons we must be concerned about patient safety. The WHO Surgical Safety Checklist is an easy to use tool that will enhance communication and teamwork amongst members of the surgical team to improve patient safety. Surgeons must take the lead to introduce the WHO Surgical Safety Checklist to the hospitals they work in. REFERENCES: 1. Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, Gawande AA: An estimation of the global volume of surgery: A modelling strategy based on available data. Lancet 2008; 372:139-44 2. Haynes AB, Massachusetts General Hospital, Department of Surgery and Harvard School of Public Health, Health Policy and Management (2008. Personal communication) 3. Makary M.A., Sexton J.B., Freischlag J.A., Millman E.A., Pryor D, et al. Patient safety in surgery. Ann Surg 2006; 243:628-632; discussion 632-635 4. http://www.safesurg.org/ (Information on how to and how not to use checklist) 5. http://www.who.int/patientsafety/safesurgery/en/

The WHO 10 OBJECTIVES OF SAFE SURGERY 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

The team will use methods known to prevent harm from administration of anaesthetics, while protecting the patient from pain. The team will operate on the correct patient at the correct site. The team will recognize and effectively prepare for life-threatening loss of airway or respiratory function. The team will recognize and effectively prepare for risk of high blood loss. The team will avoid inducing an allergic or adverse drug reaction for which the patient is known to be at significant risk. The team will consistently use methods known to minimize the risk for surgical site infection. The team will prevent inadvertent retention of instruments or sponges in surgical wounds. The team will secure and accurately identify all surgical specimens. The team will effectively communicate and exchange critical information for the safe conduct of the operation. Hospitals and public health systems will establish routine surveillance of surgical capacity, volume and results. E

BASIC SURGICAL SCIENCES EXAMINATION COLLEGE OF SURGEONS, ACADEMY OF MEDICINE OF MALAYSIA 16th to 17th October 2008 Of the 52 candidates who enrolled for the examinations, only 50 candidates appeared for the examination on 16th to 17th October 2008 in the University of Malaya Medical Centre. The examination comprised 3 components, namely, an MCQ component, an OSCE component and a Viva Voce in the fields of anatomy, physiology, pathology and principles of surgery. The Council of the College of Surgeons, Academy of Medicine of Malaysia wishes to congratulate the seven candidates listed below who passed the Examination in its entirety and wish them the very best in their future: 1. 2. 3. 4.

Chan Wei Heng Gan Chon Chean Lim Chiao Yee Ong Teng Khiam

5. 6. 7.

Sem Sei Haw Sia Kian Joo Tan Tiam Siong

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ATLS EDUCATOR REQUIRED

ADVANCED TRAUMA LIFE SUPPORT COURSE FOR DOCTORS

The Advanced Trauma Life Support (ATLS) Course will be introduced into Malaysia in the third quarter of 2009 with the assistance of the American College of Surgeons, the Royal Australasian College of Surgeons, the College of Surgeons of Singapore and Tan Tock Seng Hospital, Singapore. The College of Surgeons, Academy of Medicine of Malaysia invites suitable candidates for the position of ATLS Educator.

QUALIFICATIONS The Candidate should preferably have all of the following qualifications: 1. 2. 3. 4.

A Masters degree in Education with / without MBBS. An excellent command of English. Good communication and teaching skills. Must be prepared to attend both the Student and Instructor courses followed by the Educator course prior to being certified as an ATLS Educator.

A certified ATLS Educator is recognised by the American College of Surgeons and ATLS Centres worldwide.

JOB DESCRIPTION The ATLS Educator is required to: 1.

2.

Teach Instructors in the ATLS Instructor Courses using current teaching techniques incorporating adult learning principles. Provide guidance and assistance with the continuous improvement and ongoing development of the ATLS instructor course program • To ensure the instructors adopt contemporary adult learning principles when delivering course content • To provide expert advice on instructor course development • To provide direction for the instructor course program

TRAINING Training will be provided to the suitable candidate by the College of Surgeons, Academy of Medicine of Malaysia. The training will be conducted by an Educator from the American College of Surgeons

TIME COMMITMENT The position requires a commitment of attending up to four courses within the first twelve months and reporting to the Council of the College of Surgeons as required.

HONORARIUM The Educator will be paid an honorarium for each Instructor course.

PERKS The position as ATLS Educator is a highly respected one and enjoys recognition by the American College of Surgeons and ATLS Centres worldwide. Many countries in Asia do not have an ATLS Educator. The position of ATLS Educator therefore opens opportunities for you to be invited to many countries overseas. It also provide excellent opportunities to network with well known medical professionals throughout the world through the ATLS network.

APPLICATIONS 1.

Applications for the position of ATLS Educator should be addressed to: Dr Lum Siew Kheong President, College of Surgeons Academy of Medicine of Malaysia 19 Folly Barat, 50480 Kuala Lumpur email: [email protected]

2.

Please include the following personal details: Name, I/C, Sex, Address, Academic Qualifications with dates and Universities, Email and Telephone numbers, Current appointment, Past appointments and experience.

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PREDICTORS OF SURGICAL SITE INFECTIONS This report evaluated wound infection data gathered from 117 private-sector hospitals enrolled in the American College of Surgeons quality improvement project. The 20 hospitals with the lowest wound infection rates were compared with the 13 hospitals with the highest infection rates. Operating time and anemia proved to be important predictors of surgical site infections. The best performing hospitals had fewer trainees, lower staff turnover rates, and were smaller than hospitals with higher wound infection rates. Important factors that were not included in this report are preoperative antibiotic administration, temperature control, and control of blood sugar levels. Campbell DA Jr, Henderson WG, Englesbe MJ, et al, Surgical Site Infection Prevention: The Importance of Operative Duration and Blood Transfusion -Results of the First American College of Surgeons-National Surgical Quality Improvement Program Best Practices Initiative. J Am Coll Surg. 2008; 207:810-820

❂ ADVANCES IN COLORECTAL CANCER SCREENING Computed tomographic colonography (CTC) for detecting large adenomas Approximately 2500 asymptomatic adults aged 50 or older underwent both CTC and colonoscopy. With colonoscopy as the reference standard, CTC was 90% sensitive for detecting lesions of 10 mm or greater, with a specificity of 86%. CTC has high sensitivity for detecting large adenomas. C. Daniel Johnson et al, Accuracy of CT Colonography for Detection of Large Adenomas and Cancers. N Engl J Med 2008; 359: 1207-1217

Risk of Cancer after negative colonoscopy Nearly 1300 low-risk adults underwent colonoscopy 5 years after an initial negative colonoscopy. At follow-up, no subject had colon cancer. Adenomas were found in 16% of subjects, with advanced adenomas in only 1% overall. Implications of this study: A 5-year rescreening interval appears appropriate in selected patients. Thomas F. Imperiale et al., Five-year risk of colorectal neoplasia after negative screening colonoscopy. N Engl J Med 2008; 359: 1218- 1224

❂ ARTHROSCOPY NOT EFFECTIVE FOR KNEE OSTEOARTHRITIS Approximately 200 adults with moderate-to-severe knee osteoarthritis without large meniscal tears were randomized to physical and medical therapy alone or with arthroscopy. At 2 years, pain, stiffness, and physical function did not differ between the groups. Arthroscopic surgery does not improve outcomes in knee osteoarthritis. Kirkley A et al., A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee. N Engl J Med 2008; 359: 1097-1107

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Langkawi • 28 th – 31 st May 2009 THEME

•

“TEAM WORK IN SURGERY”

VENUE

PRECONGRESS WORKSHOPS (28 TH MAY 2009) 1. Trauma Surgery – An exciting new career prospect (Coordinator: Prof David Choon)

2.

Intercontinental comparison of surgical subspeciality training (Coordinator: Assoc Prof Razman Jarmin)

CONGRESS (29 TH – 31 ST MAY 2009) 36th AM Ismail Oration Treatment in Pancreatic Cancer

6. 7.

Metabolic surgery: the development of a surgical cure for Type 2 Diabetes Mellitus David Galloway Multidisciplinary approach to retrosternal goiter Noor Hisham Abdullah

8.

Advances in colorectal surgery – Minimally invasive surgery and TEMS Richard Molloy

Symposia 1.

Teamwork in trauma • Institutional approach to pelvic fractures Philip Iau (Singapore)

John Cameron President, American College of Surgeons

Inaugural Johns Hopkins Traveling Fellow

• Awana Porto Malai, Langkawi

• Chest trauma Euan Dickson • Maxillofacial injuries Lim Lay Hooi

RACS Traveling Fellow

Advances in Esophageal Surgery • Cardio-oesophageal junction tumours Simon Toh (UK) • The use of photodynamic therapy and radiofrequency ablation in oesophageal cancers Grant Fullarton • Minimally invasive esophagectomy David Watson

David Watson Professor of Surgery, Flinders Medical Centre, South Australia

• Iatrogenic esophageal perforation Simon Law (Hong

John Cameron Alfred Blalock Distinguished Service Professor of Surgery, Johns Hopkins Medical Institutions, USA

RCPS Glasgow Guest Lecturers Euan Dickson Glasgow Royal Infirmary, Glasgow

2.

(Australia) Kong)

3.

Teamwork in GERD • Assessment of GERD Grant Fullarton • Treatment – surgical and non-surgical David Watson • The clinical approach to Barret's oesophagus Simon Toh

4.

Pancreatic Surgery • Cystic lesions of the pancreas K Madhavan (Singapore) • Reducing mortality in severe pancreatitis C Christophi • Surgery in acute pancreatitis - minimal access options

Grant Fullarton Glasgow Royal Infirmary, Glasgow David Galloway Gartnavel General Hospital, Glasgow Paul Horgan Glasgow Royal Infirmary, Glasgow Richard Molloy Gartnavel General Hospital, Glasgow

Euan Dickson

5.

Douglas Orr Glasgow Royal Infirmary, Glasgow

Ethicon Prize Free Paper sessions / Posters

Paul Horgan

• Teamwork in liver transplant K Madhavan (Singapore) • Iatrogenic bile duct injuries John Cameron 6.

Plenaries 1. Minimising surgical errors though teamwork in Surgery

Pathologist: Nik Raihan Radiologist: Zahiah Mohamed

William Halstead – Our surgical heritage John Cameron

3.

Reducing mortality and morbidity in oesophageal surgery

7.

Teamwork in Vascular Surgery Endovascular Surgery Douglas Orr Vascular trauma Ee Boon Leong Critical limb ischaemia Douglas Orr

8.

Surgical Errors • Laparoscopic cholecystectomy Manisekar • Chest tube insertion Yeen Weng Choy • Thyroidectomy Rohaizak Muhammad

Simon Law (Hong Kong)

4.

The use of newer endoscopic imaging modalities in diagnosing early upper GI

Cancers – Tai Omari (Upper GIT Guest Lecture) 5. New technologies in surgery – How do we adapt David Watson

Multidisciplinary teams in colorectal surgery • Four case presentations by multidisciplinary teams Surgeons: Galloway, Molloy, Horgan, McCormick, April Roslani

Lum Siew Kheong

2.

Teamwork in liver surgery • Multimodality approach for liver metastatic liver disease

Please register early and also book your hotel accommodation as there are only a limited number of rooms available at the conference venue. Tel:

(603)

For more information, please contact the College's Secretariat at 2093 0100, 2093 0200 Fax: (603) 2093 0900 E-mail: [email protected], [email protected]

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Every year, the American College of Surgeons (ACS) offers International Guest Scholarships to competent young surgeons, from countries other than the United States and Canada, who demonstrate strong interests and accomplishments in teaching and research. Each Scholarship offers a stipend of USD 8,000, participation in the Clinical Congress (including a brief public presentation) and the expectation of visits to several North American clinical and research sites of the Scholar's choice. A mentor is assigned to assist the Scholar to plan his or her tour. The ACS usually provides details of the International Guest Scholarship to the College of Surgeons, Academy of Medicine of Malaysia (CSAMM) in April each year. Any surgeon interested in applying for the Scholarship is requested to write in to the CSAMM for details before 31 st March 2009.

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS ANNUAL SCIENTIFIC CONGRESS 2009 BRISBANE • 6 th – 9 th MAY 2009 The RACS has given two complimentary registrations for their Congress in Brisbane to the College of Surgeons, Academy of Medicine of Malaysia (CSAMM). The intention of this generous gesture is to foster good ties between our Colleges. Details of the meeting and program can be obtained from their website http://asc.surgeons.org/. There will not be any Urology, Orthopaedic and ENT component in the meeting. Applications are invited from members of CSAMM for these two complimentary registrations offered to the CSAMM. The following terms and conditions apply for all applicants: 1. 2. 3. 4. 5.

The application must be received at the CSAMM Secretariat before noon on 10th March 2009. The applicant must be a member of the CSAMM The applicant should not be more than 10 years post FRCS or MS. Applicants who have contributed to the activities of CSAMM and those whose papers have been accepted for oral presentation at the RACS meeting will be given preference (Please supply documentary proof) The following documents must be submitted: a) Letter of application giving the following details : name, address, telephone, fax, email, current appointment and place of work, past contribution to CSAMM activities. b) Documentary proof: Copy of NRIC and Masters / Fellowship certificate, letter of acceptance of oral paper at the RACS meeting. c) Applicants without documentary evidence as stated will not be considered.

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