The 2012 AAOS Orthopaedic Patient Safety Summit, held Aug. 5–6, 2012, in Rosemont, Ill., brought together 19 orthopaedic organizations, as well as representatives from nursing, government, and facility (hospitals, surgical centers) groups, to address the issue of surgical safety. Summit Chair William J. Robb III, MD, who also chairs the AAOS Patient Safety Committee, noted, “Without safety, there is no quality or value; safety is the kernel around which all else is built.”

In his opening remarks, Dr. Robb suggested that effective surgical safety programs require 3 critical elements: surgical team communication, validated safety processes (such as checklists) and systematic collection of safety data. He called for a new ‘culture’ of surgical safety based on partnerships among patients, surgeons, hospitals, and safety organizations. He urges surgeons to embrace emerging safety science that has benefitted many other industries and shift the focus from surgeon performance to system performance in orthopaedic care.

“A culture of surgical safety defines no ‘best’ surgical practice,” said Dr. Robb, “only ‘better’ surgical practices. Safe surgery care systems require surgeons to more effectively communicate among surgical teams members and share authority as surgical team leaders. Safe surgery is a science that can be successfully taught and learned to increase the quality care we provide for our orthopaedic patients.”

Closing the communication gaps
“To change the culture, we must first change ourselves,” said John S. Webster, MD, an orthopaedic surgeon and consultant with Healthcare Team Training. “We have to do better; we can’t keep the status quo.”

Noting that teamwork is not a “soft” skill, Dr. Webster pointed to gaps in surgeon education. “We are not exposed to human factors research or the science of medical errors, to the use of structured communication or behavioral science.”

Surgeons are, however, expected to be clinical leaders. “And what does that look like?” asked Dr. Weber. “It’s the ability to organize a team, to articulate goals, to proactively share information—accurately and across disciplines, and to listen.”

He described the following three opportunities to improve communication:

• a briefing at the beginning of the surgery enabling the team to proactively plan, identify potential difficulties, and share concerns (potential complications)
• a huddle or timeout during surgery to address specific issues related to the patient and focus the team on standardized safety measures
• a debriefing after surgery to address problems that occurred during surgery or to prevent problems during postoperative care.

Handoffs, he said, are another opportunity to improve communication—to ask questions, clarify the situation, and confirm information in the record. Checkbacks can be used to better enable providers to verify verbal orders.

A journey toward safety
According to Kit M. Song, MD, MHA, Seattle Children’s Hospital began to address surgical safety when an analysis of surgical cases during a 10-year period found a consistent number of cases referred to morbidity & mortality (M&M) review. Orthopaedics was the pilot for a hospital-wide implementation of a surgical safety initiative.

Using the surgical safety checklist developed by the World Health Organization as a basis and developing process tools (safety checklists, appropriate use criteria, and performance measures), the hospital held training sessions for everyone involved in the operating room—surgeons, anesthetists, nurses, and technicians. The process took 3 to 4 months, but resulted in a jump in compliance with the surgical checklist—from 82 percent to 98 percent. In nearly a third of the cases, using safety checklists resulted in improvements in patient care.

The hospital also introduced checklists outside the operating room, adopted clinical practice guidelines in intensive care units and the emergency department, and established standard order sets.

“There was push-back,” acknowledged Dr. Song. “The tension between productivity and safety is always an issue. And sustaining the commitment is difficult.”

100 years of surgery
According to David B. Hoyt, MD, FACS, executive director of the American College of Surgeons (ACS), quality improvement is based on the following four principles:

• established standards
• appropriate infrastructure
• rigorous data collection
• verification

Dr. Hoyt discussed various quality initiatives undertaken by the ACS, including the National Surgical Quality Improvement Program®, a validated, risk-adjusted, outcomes-based surgical database designed to measure and improve the quality of surgical care (http://site.acsnsqip.org/.)

Addressing current quality initiatives by the government and private sector, as well as calls for public reporting, Dr. Hoyt noted, “If we don’t offer something that we have confidence in, we’ll get what we’re getting. Rather than sit back and let them impose on us, we as surgeons need to rebrand ourselves to inspire quality.”

Surgeons need to move from autonomous action to collaborative work, from decisions based on authority to those based on evidence, and from assertions to measurements. “Because we can, we should,” concluded Dr. Hoyt.

Canale, Codman, and Gawande
As the keynote speaker, James H. Herndon, MD, MBA, took a look back at the status of orthopaedic surgical safety and a look forward at where the field needs to go. He credited James D. Heckman, MD, and S. Terry Canale, MD, for their efforts in establishing the AAOS “Sign Your Site” program. He also reminded the audience of the efforts of Ernest Amory Codman, MD, in the early 1900s to collect accurate outcomes data and pointed to the recent work by Atul Gawande, MD promoting use of checklists to improve surgical safety.

Dr. Herndon addressed several factors that detract from surgical safety, including fatigue, rigid surgeon attitudes and disruptive behaviors, surgical errors, and geographic variations in care.

He also proposed the following steps that the AAOS could take to improve surgical safety:

• Establishing a Center for Orthopaedic Patient Safety that would identify success stories and collect and distribute data
• Increasing collaboration with other organizations such as the Joint Commission and the Agency for Healthcare Research and Quality
• Partnering with “Choosing Wisely,” an initiative of the ABIM Foundation to identify five tests or procedures that are of questionable necessity
• Continuing to emphasize use of surgical checklists and signing/marking surgical sites

Watch for additional coverage of the AAOS Orthopaedic Patient Safety Summit in next month’s issue of AAOS Now.

Mary Ann Porucznik is managing editor of AAOS Now. She can be reached at porucznik@aaos.org