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Shouldering the burden of adverse event As primary care givers and clinical leaders, surgeons will not infrequently find themselves taking an active part in adverse event reporting. The professional responsibilities involved with managing adverse outcomes can b...

Situation awareness: identifying Situation awareness: identifying

Situational awareness: understanding the work environment and working well within it Nowhere is teamworking more important than in managing the flow of information within health care. Poor communica - tion can lead to misinformation to patients and sta ff and d...

Six Sigma Six Sigma refers to another business performance meth odology that has been adopted for use in health care. The fundamental objective of the Six Sigma methodology is the implementation of a measurement-based strategy that focuses on process impro ve...

Supporting a safety culture Adverse events and near misses go unreported for many reasons, including a fear of blame and the potential for litiga - - tion. Clinical risk management is an integrated process, based on risk identification, analysis and control of...

Surgical Safety Checklist B efore induction of anaesthesia B efore skin incision (with nurse, anaesthetist and surgeon) (with at least nurse and anaesthetist) Has the patient confirmed his/her identity, Confirm all team members have site, procedure, and consent?...

Systems thinking and leadership In a system as complex as health care, ‘systems’ thinking allows the whole system and the relationships of the parts to be considered rather than just isolated functions. Health care is a shared resource with many interdependen...

THE PROCESS OF SURGICAL CARE Patients attend surgeons in many di ff erent settings depending on whether they present electively (scheduled) or urgently (unscheduled). An elective patient’s journey is usually predict - - able and typically starts with referral ...

THE QUALITY IMPROVEMENT PATHWAY Quality improvement can be applied to almost any step, process or activity . The science of improvement is an applied science that prioritises innovation, rapid-cycle testing and spread with the aim of identifying what changes...

Technical and operative errors In surgery , the person rather than systems approach empha - sises the accountability of the surgeon, who, unlike colleagues in other medical disciplines, when operating carries specific responsibilities. During a surgical procedu...

The person approach Human performance principles tell us that humans are fallible and that errors can occur through doing the wrong thing – errors of commission; failure to act – errors of omission; or errors of execution – doing the right thing incorrectly...

The system approach Health systems add complex organisational structures to human fallibility , thus substantially increasing the potential for errors. A systems approach to error recognises that adverse events rarely have an isolated cause and that they are b...

UNDERSTANDING PATIENT SAFETY UNDERSTANDING PATIENT SAFETY

When things go wrong: open disclosure Communicating honestly with patients after an adverse event, or open disclosure , includes a full explanation of what happened, the potential consequences and what will be done to fix the problem. Safe care also involves ta...

teamwork errors Operating theatres have been described as ‘among the most - complex political, social and cultural structures that exist, full of ritual, drama, hierarchy and too often conflict’. In such an environment, systems should seek to prevent error by ...

CLINICAL OUTCOMES, AUDIT AND IMPROVEMENT tients Clinical audit, a function of clinical governance, is the means by which the health care being provided is compared with accepted standards. It allows care providers and patients to know how their service is doi...

COMMUNICATION Professional behaviour and maintaining fitness to practice Professionalism is an important component of patient safety . This embraces attitudes and behaviours that serve the patient’s best interests above and beyond other considerations. Organ i...

Checklists Checklists in the operating theatre environment are now accepted as standard safety protocols since the Safe Surgery Saves Lives Study Group at WHO published its results. The use of a perioperative surgical safety checklist in eight hospitals aroun...