Surgical Patient Safety Summit cochairs David B. Hoyt, MD, FACS (left) of the ACS, and William J. Robb III, MD (right), of the AAOS, with AAOS Immediate Past President David D. Teuscher, MD.

AAOS Now

Published 10/1/2016
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Terry Stanton; Paul Zemaitis

AAOS Puts Patient Safety at the Forefront

National Surgical Safety Summit's stakeholders propose national standards
Taking a cue from the adage about safety in numbers, more than 150 representatives from more than 75 healthcare organizations came together near AAOS headquarters in August to take part in the inaugural National Surgical Patient Safety Summit (NSPSS).

Sponsored by the AAOS and the American College of Surgeons (ACS), the summit had two goals: to develop new safety standards for surgical care and surgical education and to identify surgical safety knowledge gaps and research priorities.

"So much of our continuing education focuses on surgical technique, but almost no attention is given to nontechnical skills, which are equally if not more important," said William J. Robb III, MD, cochair of the NSPSS and past chair of the AAOS Patient Safety Committee. "Surgical safety improves when nontechnical strategies, tools, and behaviors are combined with proficient surgical skills. Each member of the surgical team needs to know how to effectively communicate and appropriately adapt during an adverse situation. An empowered, well-trained surgical team improves surgeon performance and patient outcomes."

"Patient safety has always been the surgical community's highest priority, and bringing together surgical organizations and other safety stakeholder groups reinforces the importance of safety and allows new collaborative efforts needed to propose and implement surgical patient safety standards," said David B. Hoyt, MD, FACS, NSPSS cochair and ACS executive director. "This summit and its resulting recommendations are timely and innovative, and will have a very positive impact on the quality of surgical patient care."

Prior to the summit, four work groups consisting of representatives from the AAOS, ACS, American Society of Anesthesiologists (ASA), and Association of periOperative Registered Nurses (AORN) convened to identify key issues in surgical safety and to make recommendations relating to all surgical team members, surgical institutions, medical and nursing schools, surgical residency and fellowship programs, and credentialing organizations. These recommendations addressed the creation and adoption of standardized approaches over the entirety of the surgical care episode.

Dr. Hoyt explained that the genesis for the summit occurred in combined discussions between the ACS and the AAOS "to address a critical unmet need because safety remains a challenge for the surgical community and we have not gotten to where we need to go." He and Dr. Robb, along with David D. Teuscher, MD, AAOS immediate past president, envisioned a "consensus-type conference based on a set of principles to which we would hold ourselves accountable."

The work groups were organized along four key charges: Definitions, Processes, Tools, and Standards; Human Factors and Safety Culture; Data and Technology; and Education.

Work Group 1: Definitions, Processes, Tools, and Standards
Work Group 1 defined patient safety as the highest priority for surgeons and their organizations. "We look at safety as being the basis for quality and value," said Dwight W. Burney III, MD, who presented common definitions for surgical safety. "It's hard to imagine that you can have any kind of quality if you don't have safety. If value is quality over cost, and quality has to do with safety, efficacy, the patient experience, timeliness, efficiency, and equitability, then without safety you don't have quality—or value."

In establishing terminology, he said, "We have tried to stay away from inflammatory terms like 'medical error.' We have tried to adopt a 'systems approach' and prefer 'adverse events,' 'near misses,' and in fields that deal with paired organs or laterality, 'wrong-event surgery'—wrong patient, wrong site, wrong side, wrong implant, or wrong operation."

Dr. Burney also addressed the concepts of "high reliability," which have been identified through observation of complex high-risk industries in which adverse events may have catastrophic outcomes. In its report, the work group stated the following: "High-reliability organizations acknowledge human fallibility; system complexity; ambiguity and uncertainty; limitations of individuals in learning, training, and attention; continuity gaps; negative effects of fatigue on human performance; dynamic conditions; difficult decision making under time constraints; and numerous system vulnerabilities. The overriding principle of high reliability is 'collective mindfulness.'" (AORN has referred to this as "wariness.") Work Group 1 stated that surgery qualifies as a high-risk endeavor.

Organizations using high-reliability principles, the report noted, demonstrate shared characteristics that serve to reduce adverse events by adopting mindsets, strategies, and cultural mandates, including the following:

  • Preoccupation with failure: Focus on potential (near miss) or actual adverse events and allocate resources and time to prevent them.
  • Sensitivity to operations: Continually evaluate local operational team and system performance and be attentive to variation—both positive (what works) and negative (what doesn't).
  • Reluctance to simplify: Do not accept the initial, most probable, or easiest explanation for an adverse event. Investigate with a focus on "what went wrong" rather than "who went wrong."
  • Commitment to resilience: Recognize that errors are inevitable. Maintain team operations despite workflow disruptions.
  • Deference to expertise: Recognize that all team members may be situational leaders based on their unique skills and knowledge.

Dr. Robb addressed surgical safety strategies and tools required across the phases of care, which include:

  • Preoperative evaluation and preparation phase:
    • surgical shared decision making
    • Agency for Healthcare Research and Quality (AHRQ) Health Literacy Universal Precautions Toolkit
  • Immediate preop phase:
    • informed surgical consent and documentation
    • surgical site identification and marking
  • Intraoperative phase:
    • World Health Organization (WHO) Safe Surgery Checklist
    • surgical team brief
    • surgical team time-out
    • surgical team de-brief
  • Immediate postop phase:
    • surgical information transfer (handoffs)—SBAR (situation, background, assessment, recommendation)
  • Postop discharge and recovery phase:
    • surgical information transfer (handoffs)—I-PASS (introduction, patient assessment, situation, safety concerns)

    Use of these tools, such as the safe surgery checklist by itself, has not provided as much safety as expected and hoped, according to Dr. Robb. "Team member and team behaviors supporting safety with the use of the checklist make the checklist effective," he said.

    Work Group 2: Human Factors and Safety Culture
    Andrew W. Grose, MD,
    presented the work group's report addressing ways to foster the optimal performance and well-being of all team members engaged in the care of the patient. Findings and recommendations focused on four main components: the individual, the team, the situation, and the system.

    "With respect to the creation of a safety culture," the work group reported, "we believe that available evidence supports safety as a social construct, dependent on highly functioning teams at all levels and between all levels within the organization."

    At the individual level, "Optimal performance of any individual team member within any system requires maintenance and support," said Dr. Grose. He noted the current "epidemic of provider burnout," which is associated with provider and patient harm. "There needs to be a paradigm shift—take care of ourselves, take care of our colleagues, take care of our patients."

    At the team level, the two goals of effective teamwork are to create a broad and accurate shared mental model for effective problem management, and to maintain open lines of communication, according to Dr. Grose. Available tools in this endeavor include Crew Resource Management and TeamSTEPPS™. The work group strongly recommends that teamwork training be provided "to all providers in an interdisciplinary fashion at the earliest possible phases of training" and that developmental work in teamwork skills "be ongoing throughout postgraduate training and included in professional development thereafter."

    At the situation level, the crucial issue is the "gap between work as imagined and work as done," he said. He described the concept of threat management and task adaptation, a descriptive model of performance variability in high-stakes situations like surgery. It calls on human performers to anticipate, recognize, and respond to situations as they unfold.

    "Optimal medical practice," the work group stated, "should balance anticipation, recognition, and responsiveness, as it is this basis from which quality and safety will emerge."

    At the system level, the work group observed, "the most effective safety management systems exhibit common traits that have come to be described as high-reliability principles. At their core, these principles embrace human frailty, and acknowledge that high degrees of quality and safety emerge as a function of complex social dynamics often referred to as 'safety culture.'"

    The work group expressed its belief that the continued joint cooperation of the "interdependent professional organizations" that have committed to safety improvement through the NSPSS and other efforts "must be the driving force behind the changing landscape of the U.S. healthcare system."

    Work Group 3: Data and Technology
    David C. Ring, MD, PhD,
    presented the first portion of the work group's report, in which the overall goal was to propose a system for reporting safety and quality data, preferably directly from the electronic health record (EHR), to inform efforts to limit adverse events and patient harms.

    The work group's four broad recommendations for data reporting were the following:

    • Consistency in reporting is essential to analysis. One cannot be selective in what is reported.
    • Uniform definitions provide a common standardized method for healthcare providers to submit, collect, and exchange information regarding patient safety events.
    • "Usability" means that data must be accessible. Some safety events occur so infrequently that it is nearly impossible to learn how to prevent an incident using only one institution's data.
    • Collaboration is essential among hospitals, care providers, and other parties, which need to work together in a nonpunitive environment and have access to information so they can learn from their peers.

    Laurent G. Glance, MD, discussed the changing role of clinical data registries. Performance feedback using a data-driven approach is key to improving patient outcomes and safety, he noted.

    The work group stated the following goal: "To endorse a system in which healthcare providers can report unambiguous patient safety and quality data, preferably directly from the EHR, from which the entire health system can [draw] to prevent adverse patient safety incidents."

    Work Group 4: Education
    According to Philip F. Stahel, MD, who presented the report on education issues, the overall goal was to recommend educational programs arising out of the recommendations and priorities identified at the summit. Targets of the educational program will be surgeons as well as residents and medical students, persons across the perioperative team, and individual institutions and healthcare systems.

    Next steps
    Dr. Robb concluded the summit by laying out an action plan for gaining consensus around the recommendations. A consensus statement will be written and sent to each of the attending organizations asking for their formal endorsement. Each organization will then nominate a champion to participate in another meeting where implementation would be the main focus. The proceedings from the meeting will be prepared for publication. 

    "We believe that the implementation of these standards will guide surgical teams and members to achieve the ultimate goal of ensuring safe and optimal surgical patient outcomes," said Dr. Teuscher.

    Terry Stanton is the senior science writer for AAOS Now. He can be reached at tstanton@aaos.org

    Paul Zemaitis, MPH, is the lead orthopaedic safety specialist in the AAOS department of research and scientific affairs. He can be reached at zemaitis@aaos.org