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Improving Patient Safety in the Dutch OR’s Johan Lange Department of Surgery Erasmus University Medical Center Rotterdam.

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Presentation on theme: "Improving Patient Safety in the Dutch OR’s Johan Lange Department of Surgery Erasmus University Medical Center Rotterdam."— Presentation transcript:

1 Improving Patient Safety in the Dutch OR’s Johan Lange Department of Surgery Erasmus University Medical Center Rotterdam

2 Historical development crtitical success factors in surgery 021st century instruments&apparatus Professional training medication (anesthetics, AB, heparin) Risk factors patient Best practices, protocols (patientsafety) factor Results

3 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

4 Adverse events in the Dutch OR (2005)  adverse events in operations/year (all specialisms)  adverse events in surgery: 2.5% of operations  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:

5 Adverse events in surgery  36% of all adverse events in health care  Avoidable: 40%  >50%: related to the individual surgeon

6 Tenerife 1977: 583 death

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8 Aviation before 1977: autocratic leadership =

9 Incidents in aviation: ‘75% (human factors)-rule’  accident-analysis, blackbox, simulator-research: ‘75% rule’: 75% of incidents caused by teamwork-failure ( human factors, chain of errors, human performance limitation)

10 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)

11 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)

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13 CRM: technically-complex high risk industries

14 OR 21st century: technically-complex high risk environment

15 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."

16 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

17 VWS-Report ‘Here you are working safely, or you do not work here at all’ ‘The safety of Care’ 2004 Rein Willems (CEO Shell)  Recommendations: 1) Safety management system in all hospitals (VMS)  Blamefree incident-reporting

18 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

19 team or….

20 Ongoing taboos in the OR  Failability of the surgeon  Horizontal communication  Mistakes (Culture of Name, Blame and Shame)

21 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

22 Autocratic leadership with vertical communication

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24 Ego’s & culture: idolatry

25 CRM: new leadership in the OR-team  Open communication  Coaching/Bindend/Sharing  Applying protocols and S.O.P.’s  Blamefree reporting

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

27 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

28 Teamperformance: CRM + expertise (scenario-based simulation)

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30 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

31 Wrong side-surgery

32 Eye-hospital Rotterdam :disappearance of wrong-side surgery

33 TOP (Time Out Procedure)+ Johan Lange, Linda Wauben, Conny Dekker, Geert Kazemier, Jan Klein, Jeroen Peters Departments of Anesthesiology and Surgery Erasmus MC

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36 Results pilot TOP+  Duration 1-2’  Compliance high  In 15% of operations incidents can be avoided  Anesthiology assistant: director

37 Time Out=double check Time-Out

38 SURPASS (SURgical PAtient Safety System) – perioperative checklist  Validated (Marja Boermeester)  Transfermoments (ward-holding- OR)  Stopping rules

39 Teamwork (CRM): culture shock/paradigma shift  Transforming individual professionals into a professional team  Changing training/medical education  New shared responsabilities  New professional relationships

40 Soft??

41 Medical eduction/training: teamfunctioning

42 Patient safety in the OR: planning  Short term-vision:  Bureaucracy-reflex model  Regulations  Audit  Long term-vision  Regulations  Audit  Transparance  Teamconcept

43 Historical development crtitical success factors in surgery 021st century instruments&apparatus Professional training medication (anesthetics, AB, heparin) Risk factors patient Best practices, protocols (patientsafety) factor Results

44 Historical development crtitical success factors in surgery 021st century instruments&apparatus Professional training medication (anesthetics, AB, heparin) Risk factors patient Best practices, protocols (patientsafety) factor Results Teamwork!

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