Principles Of Safe General Surgery Notes

Principles Of Safe General Surgery Introduction

• Since the last three decades, tremendous growth has been seen in a number of surgeries performed. World has also seen advances in all medical fields including surgery.
• Minimal access surgery is one of the major changes which happened in these 30 years and has been accepted very well by surgeons and patients.
• In fact, surgeon’s aim is not only to operate but also operate with minimal morbidity and least mortality. Minimal access surgery or laparoscopic surgery is one example of such developments. It is also important that many such skilled surgeries require training.
• In a few cases, learning curve is long. An attempt to do surgery may land with complications, compromising patient’s safety. Legal issues are also becoming more common in the last 3 decades.
• Thus, safe practice of general surgery aims to achieve maximum success. It will also decrease litigations for surgeons. Let us look at those principles.

Read And Learn More: Basic Principles Of Surgery Notes

Who Surgical Safety Checklist (2008)

• World Health Organisation (WHO) in 2008 released a checklist consisting of 19 items. If one follows this system, one can decrease number of deaths/blunders/ complications related to surgery.
• Worldwide a large number of deaths or errors occur in the operating table which results in mortality. It is a simple checklist to implement.
• Many centres in the world have used this and have reduced the complications related to instruments or adverse events which occur in the hospital before during or after conduct of a surgical procedure.
• Dr Makary, Professor of Surgery, Johns Hopkins University School of Medicine, is the creator of The Surgery Checklist.
• Surgery is basically a teamwork. If the entire team consisting of surgeon, anaesthetist and nursing staff know about the patient’s disease, problems, if any, including allergy, indication for surgery, possible complications and recovery in the postoperative period, many of the complications could have been avoided.
• Every surgery has a critical event. Before proceeding, the surgeon can discuss this with his colleagues/other surgeons and go ahead.
• Classical example: Before ligation and division of cystic duct in cases of difficult cholecystectomy. A wrong decision at this stage can have serious consequences of division of CBD and associated with serious complications and mortality also.
• In Western countries, the consultant who examines the patient may not be the operating surgeon. Often appointments are given and patient comes to the hospital on the day of surgery.
• Surgeon comes to OT, he will see a few CT scans or reports and operate. He might have been busy also. Because of this, wrong side of the patient has been operated many a time.
• Wrong side breast lump has been removed. Due to communication errors between nursing staff and surgeons, nurses may not be well prepared for an unexpected emergency which necessitates additional set of instruments, e.g. vascular injury.
• If a prior intimation is given to them, such situations can be avoided. This can happen anywhere and hence, WHO advises the use of checklist.
• Sign in means checking before induction of anaesthesia, time out means before skin incision and sign out means before the patient leaves the operating room. These principles help in avoiding operating on

Surgical Safety Checklist:

wrong patients, wrong side, wrong procedure. Anticipating major events such as vascular injuries or excessive bleeding, etc. are also part of the checklist.

• It also helps in better coordination between operating surgeons, anaesthetists, and nurses. Simple checklists will avoid such gross blunders or errors. Counting mops and needles are also part of this. The list can be modified depending upon the local hospital policies and practices.
• Modification of this checklist, a single 5-step approach, advocated by the National Patient Safety Agency (NPSA) for all patients in England and Wales undergoing surgical procedures is given below.

Five Steps to Safer Surgery

A simple 5-step approach, “Five Steps to Safer Surgery” is a surgical safety checklist. It involves briefing, sign-in, timeout, sign-out and debriefing.

1. Briefing: Before the procedure starts. A briefing about the patient, what is the disease, who is doing the surgery, who is assisting, what is the plan what are the possible complications, is there possibility of excessive blood loss.
   • Please note safety list is not about discussing complications of surgery with the patient but briefing the team. One example is carcinoma parotid with doubtful infiltration of facial nerve.
   • Here a nurse is requested to keep nerve stimulator ready, anaesthesia consultant is informed that muscle relaxants must be avoided and a plastic surgery team is informed in advance to ensure their availability.
2. Sign in: Before induction of anaesthesia, reconfirm whether consent is taken or not, presence of allergy, anticipated blood loss, anaesthesia machine and drugs. Check the side of marking specially when lesions are small—breast lumps, lymph nodes.
3. Time out: Stop for a moment before starting incision. Again, confirm patient identity, surgical site infection bundle, thromboprophylaxis, antibiotics or any adverse events which can happen—maybe all these are already discussed but check again.
4. Sign out: At the end of the procedure, check sponge count, needle and sharp count, check position of tubes and tourniquets. Discuss possible complications with doctors as well as nurses in the team.
5. Debriefing: At the end of the procedure, discuss again what has been done and what should not have been done. Example: Why did I injure internal jugular vein in thyroidectomy? Why did the creation of pneumoperitoneum take a long time? Was there any instrument failure? Should anything else be improved? This is done with a view to improving care of patients in the future.