Skip to main content
Top
Published in: Patient Safety in Surgery 1/2014

Open Access 01-12-2014 | Editorial

Current challenges and future perspectives for patient safety in surgery

Authors: Philip F Stahel, Cyril Mauffrey, Nathan Butler

Published in: Patient Safety in Surgery | Issue 1/2014

Login to get access

Excerpt

As surgeons, we are arguably practitioners of one of the most entitled, rewarded and rewarding occupations in the world. We are privileged to meet and interact with previously unknown individuals on a most intimate and personal level, and to make a positive difference at some of the worst times in their lives. We eventually know these people in ways they cannot know themselves, and we are able help them in ways they cannot help themselves. We are empowered to the completely legal action of putting a knife to work in a human body. With proper indication and distinguished technical skills, our surgical blade can provide a cure for acute and chronic ailments in the most vulnerable population of human beings. In return, our patients reward us with their unlimited trust in our knowledge, skills, and ability to deliver them to restored health and an improved quality of life. Unfortunately, we fail to restore our patients’ health and quality of life more often than we appreciate. While all physicians take the Hippocratic Oath to abstain from doing harm (”Primum non nocere”), our patients are frequently caught in the ‘friendly fire’ of surgical care – health care providers causing unintentional harm when their only intent was to help [1, 2]. …
Appendix
Available only for authorised users
Literature
1.
go back to reference Walton M, Kerridge I: Do no harm: is it time to rethink the Hippocratic Oath?. Med Educ. 2014, 48: 17-27. 10.1111/medu.12275.CrossRefPubMed Walton M, Kerridge I: Do no harm: is it time to rethink the Hippocratic Oath?. Med Educ. 2014, 48: 17-27. 10.1111/medu.12275.CrossRefPubMed
3.
go back to reference Newman-Toker DE, Pronovost PJ: Diagnostic errors - the next frontier for patient safety. JAMA. 2009, 301: 1060-1062. 10.1001/jama.2009.249.CrossRefPubMed Newman-Toker DE, Pronovost PJ: Diagnostic errors - the next frontier for patient safety. JAMA. 2009, 301: 1060-1062. 10.1001/jama.2009.249.CrossRefPubMed
4.
go back to reference Griffen FD, Stephens LS, Alexander JB, Bailey HR, Maizel SE, Sutton BH, Posner KL: The American College of Surgeons' closed claims study: new insights for improving care. J Am Coll Surg. 2007, 204: 561-569. 10.1016/j.jamcollsurg.2007.01.013.CrossRefPubMed Griffen FD, Stephens LS, Alexander JB, Bailey HR, Maizel SE, Sutton BH, Posner KL: The American College of Surgeons' closed claims study: new insights for improving care. J Am Coll Surg. 2007, 204: 561-569. 10.1016/j.jamcollsurg.2007.01.013.CrossRefPubMed
5.
go back to reference Greenberg CC, Regenbogen SE, Studdert DM, Lipsitz SR, Rogers SO, Zinner MJ, Gawande AA: Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg. 2007, 204: 533-540. 10.1016/j.jamcollsurg.2007.01.010.CrossRefPubMed Greenberg CC, Regenbogen SE, Studdert DM, Lipsitz SR, Rogers SO, Zinner MJ, Gawande AA: Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg. 2007, 204: 533-540. 10.1016/j.jamcollsurg.2007.01.010.CrossRefPubMed
6.
go back to reference Earnshaw JJ, Alderson D: Sustainable global surgery. Br J Surg. 2014, 101: 1-2.CrossRef Earnshaw JJ, Alderson D: Sustainable global surgery. Br J Surg. 2014, 101: 1-2.CrossRef
7.
go back to reference Wang Y, Eldridge N, Metersky ML, Verzier NR, Meehan TP, Pandolfi MM, Foody JM, Ho SY, Galusha D, Kliman RE, Sonnenfeld N, Krumholz HM, Battles J: National trends in patient safety for four common conditions, 2005-2011. N Engl J Med. 2014, 370: 341-351. 10.1056/NEJMsa1300991.PubMedCentralCrossRefPubMed Wang Y, Eldridge N, Metersky ML, Verzier NR, Meehan TP, Pandolfi MM, Foody JM, Ho SY, Galusha D, Kliman RE, Sonnenfeld N, Krumholz HM, Battles J: National trends in patient safety for four common conditions, 2005-2011. N Engl J Med. 2014, 370: 341-351. 10.1056/NEJMsa1300991.PubMedCentralCrossRefPubMed
8.
go back to reference Stahel PF: The 10th year of the “Universal Protocol”: are our patients safer today?. Bone Joint-360. 2014, 3: 7-10. 10.1302/2048-0105.31.360215.CrossRef Stahel PF: The 10th year of the “Universal Protocol”: are our patients safer today?. Bone Joint-360. 2014, 3: 7-10. 10.1302/2048-0105.31.360215.CrossRef
9.
10.
go back to reference Mascherek AC, Schwappach DL, Bezzola P: Frequency of use and knowledge of the WHO-surgical checklist in Swiss hospitals: a cross-sectional online survey. Patient Saf Surg. 2013, 7: 36-10.1186/1754-9493-7-36.PubMedCentralCrossRefPubMed Mascherek AC, Schwappach DL, Bezzola P: Frequency of use and knowledge of the WHO-surgical checklist in Swiss hospitals: a cross-sectional online survey. Patient Saf Surg. 2013, 7: 36-10.1186/1754-9493-7-36.PubMedCentralCrossRefPubMed
11.
go back to reference Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, Merry AF, Moorthy K, Reznick RK, Taylor B, Gawande AA, Safe Surgery Saves Lives Study Group: A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009, 360: 491-499. 10.1056/NEJMsa0810119.CrossRefPubMed Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, Merry AF, Moorthy K, Reznick RK, Taylor B, Gawande AA, Safe Surgery Saves Lives Study Group: A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009, 360: 491-499. 10.1056/NEJMsa0810119.CrossRefPubMed
12.
go back to reference Donald GW, Sunjaya D, Lu X, Chen F, Clerkin B, Eibl G, Li G, Tomlinson JS, Donahue TR, Reber HA, Hines OJ: Perioperative antibiotics for surgical site infection in pancreaticoduodenectomy: does the SCIP-approved regimen provide adequate coverage?. Surgery. 2013, 154: 190-196. 10.1016/j.surg.2013.04.001.CrossRefPubMed Donald GW, Sunjaya D, Lu X, Chen F, Clerkin B, Eibl G, Li G, Tomlinson JS, Donahue TR, Reber HA, Hines OJ: Perioperative antibiotics for surgical site infection in pancreaticoduodenectomy: does the SCIP-approved regimen provide adequate coverage?. Surgery. 2013, 154: 190-196. 10.1016/j.surg.2013.04.001.CrossRefPubMed
13.
go back to reference de Vries EN, Dijkstra L, Smorenburg SM, Meijer RP, Boermeester MA: The SURgical PAtient Safety System (SURPASS) checklist optimizes timing of antibiotic prophylaxis. Patient Saf Surg. 2010, 4: 6-10.1186/1754-9493-4-6.PubMedCentralCrossRefPubMed de Vries EN, Dijkstra L, Smorenburg SM, Meijer RP, Boermeester MA: The SURgical PAtient Safety System (SURPASS) checklist optimizes timing of antibiotic prophylaxis. Patient Saf Surg. 2010, 4: 6-10.1186/1754-9493-4-6.PubMedCentralCrossRefPubMed
14.
go back to reference Mehler PS, Colwell CB, Stahel PF: A structured approach to improving patient safety: Lessons from a public safety-net system. Patient Saf Surg. 2011, 5: 32-10.1186/1754-9493-5-32.PubMedCentralCrossRefPubMed Mehler PS, Colwell CB, Stahel PF: A structured approach to improving patient safety: Lessons from a public safety-net system. Patient Saf Surg. 2011, 5: 32-10.1186/1754-9493-5-32.PubMedCentralCrossRefPubMed
16.
go back to reference Murphy JG, Stee L, McEvoy MT, Oshiro J: Journal reporting of medical errors: the wisdom of Solomon, the bravery of Achilles, and the foolishness of Pan. Chest. 2007, 131: 890-896. 10.1378/chest.06-2420.CrossRefPubMed Murphy JG, Stee L, McEvoy MT, Oshiro J: Journal reporting of medical errors: the wisdom of Solomon, the bravery of Achilles, and the foolishness of Pan. Chest. 2007, 131: 890-896. 10.1378/chest.06-2420.CrossRefPubMed
17.
go back to reference Stahel PF, Clavien PA, Hahnloser D, Smith WR: A new journal devoted to patient safety in surgery: the time is now!. Patient Saf Surg. 2007, 1: 1-10.1186/1754-9493-1-1.PubMedCentralCrossRefPubMed Stahel PF, Clavien PA, Hahnloser D, Smith WR: A new journal devoted to patient safety in surgery: the time is now!. Patient Saf Surg. 2007, 1: 1-10.1186/1754-9493-1-1.PubMedCentralCrossRefPubMed
20.
go back to reference Ottenwess DM, Lamberti MA, Ottenwess SP, Dresevic AD: Medical malpractice tort reform. Radiol Manage. 2011, 33: 30-35.PubMed Ottenwess DM, Lamberti MA, Ottenwess SP, Dresevic AD: Medical malpractice tort reform. Radiol Manage. 2011, 33: 30-35.PubMed
21.
go back to reference Miglioretti DL, Smith-Bindman R: Overuse of computed tomography and associated risks. Am Fam Physician. 2011, 83: 1252-1254.PubMed Miglioretti DL, Smith-Bindman R: Overuse of computed tomography and associated risks. Am Fam Physician. 2011, 83: 1252-1254.PubMed
22.
go back to reference Brenner DJ: Should we be concerned about the rapid increase in CT usage?. Rev Environ Health. 2010, 25: 63-68.CrossRefPubMed Brenner DJ: Should we be concerned about the rapid increase in CT usage?. Rev Environ Health. 2010, 25: 63-68.CrossRefPubMed
23.
go back to reference Pearce MS, Salotti JA, Little MP, McHugh K, Lee C, Kim KP, Howe NL, Ronckers CM, Rajaraman P, Sir Craft AW, Parker L, Berrington de González A: Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet. 2012, 380: 499-505. 10.1016/S0140-6736(12)60815-0.PubMedCentralCrossRefPubMed Pearce MS, Salotti JA, Little MP, McHugh K, Lee C, Kim KP, Howe NL, Ronckers CM, Rajaraman P, Sir Craft AW, Parker L, Berrington de González A: Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet. 2012, 380: 499-505. 10.1016/S0140-6736(12)60815-0.PubMedCentralCrossRefPubMed
24.
go back to reference Goldfarb S, Morrison G: The 3-year medical school–change or shortchange?. N Engl J Med. 2013, 369: 1087-1089. 10.1056/NEJMp1306457.CrossRefPubMed Goldfarb S, Morrison G: The 3-year medical school–change or shortchange?. N Engl J Med. 2013, 369: 1087-1089. 10.1056/NEJMp1306457.CrossRefPubMed
25.
go back to reference Drolet BC, Sangisetty S, Tracy TF, Cioffi WG: Surgical residents' perceptions of 2011 Accreditation Council for Graduate Medical Education duty hour regulations. JAMA Surg. 2013, 148: 427-433. 10.1001/jamasurg.2013.169.CrossRefPubMed Drolet BC, Sangisetty S, Tracy TF, Cioffi WG: Surgical residents' perceptions of 2011 Accreditation Council for Graduate Medical Education duty hour regulations. JAMA Surg. 2013, 148: 427-433. 10.1001/jamasurg.2013.169.CrossRefPubMed
26.
go back to reference Nakayama DK, Taylor SM: SESC Practice Committee survey: surgical practice in the duty-hour restriction era. Am Surg. 2013, 79: 711-715.PubMed Nakayama DK, Taylor SM: SESC Practice Committee survey: surgical practice in the duty-hour restriction era. Am Surg. 2013, 79: 711-715.PubMed
27.
go back to reference Stahel PF, Flierl MA: Orthopedic residency training in Germany: an endangered species?. Orthopedics. 2008, 31: 742-743. 10.3928/01477447-20080801-32.CrossRefPubMed Stahel PF, Flierl MA: Orthopedic residency training in Germany: an endangered species?. Orthopedics. 2008, 31: 742-743. 10.3928/01477447-20080801-32.CrossRefPubMed
28.
go back to reference Businger AP, Laffer U, Kaderli R: Resident work hour restrictions do not improve patient safety in surgery: a critical appraisal based on 7 years of experience in Switzerland. Patient Saf Surg. 2012, 6: 17-10.1186/1754-9493-6-17.PubMedCentralCrossRefPubMed Businger AP, Laffer U, Kaderli R: Resident work hour restrictions do not improve patient safety in surgery: a critical appraisal based on 7 years of experience in Switzerland. Patient Saf Surg. 2012, 6: 17-10.1186/1754-9493-6-17.PubMedCentralCrossRefPubMed
29.
go back to reference Starmer AJ, Sectish TC, Simon DW, Keohane C, McSweeney ME, Chung EY, Yoon CS, Lipsitz SR, Wassner AJ, Harper MB, Landrigan CP: Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. JAMA. 2013, 310: 2262-2270. 10.1001/jama.2013.281961.CrossRefPubMed Starmer AJ, Sectish TC, Simon DW, Keohane C, McSweeney ME, Chung EY, Yoon CS, Lipsitz SR, Wassner AJ, Harper MB, Landrigan CP: Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. JAMA. 2013, 310: 2262-2270. 10.1001/jama.2013.281961.CrossRefPubMed
30.
go back to reference Horwitz LI: Does improving handoffs reduce medical error rates?. JAMA. 2013, 310: 2255-2256. 10.1001/jama.2013.281827.CrossRefPubMed Horwitz LI: Does improving handoffs reduce medical error rates?. JAMA. 2013, 310: 2255-2256. 10.1001/jama.2013.281827.CrossRefPubMed
31.
go back to reference Hannaford N, Mandel C, Crock C, Buckley K, Magrabi F, Ong M, Allen S, Schultz T: Learning from incident reports in the Australian medical imaging setting: handover and communication errors. Br J Radiol. 2013, 86: 20120336-10.1259/bjr.20120336.PubMedCentralCrossRefPubMed Hannaford N, Mandel C, Crock C, Buckley K, Magrabi F, Ong M, Allen S, Schultz T: Learning from incident reports in the Australian medical imaging setting: handover and communication errors. Br J Radiol. 2013, 86: 20120336-10.1259/bjr.20120336.PubMedCentralCrossRefPubMed
32.
go back to reference Gopaldas RR, Chu D, Dao TK, Huh J, LeMaire SA, Coselli JS, Bakaeen FG: Impact of ACGME work-hour restrictions on the outcomes of coronary artery bypass grafting in a cohort of 600,000 patients. J Surg Res. 2010, 163: 201-209. 10.1016/j.jss.2010.03.014.CrossRefPubMed Gopaldas RR, Chu D, Dao TK, Huh J, LeMaire SA, Coselli JS, Bakaeen FG: Impact of ACGME work-hour restrictions on the outcomes of coronary artery bypass grafting in a cohort of 600,000 patients. J Surg Res. 2010, 163: 201-209. 10.1016/j.jss.2010.03.014.CrossRefPubMed
33.
go back to reference Peabody T, Nestler S, Marx C, Pellegrini V: Resident duty-hour restrictions-who are we protecting? AOA critical issues. J Bone Joint Surg Am. 2012, 94: e131-CrossRefPubMed Peabody T, Nestler S, Marx C, Pellegrini V: Resident duty-hour restrictions-who are we protecting? AOA critical issues. J Bone Joint Surg Am. 2012, 94: e131-CrossRefPubMed
34.
go back to reference Desai SV, Feldman L, Brown L, Dezube R, Yeh HC, Punjabi N, Afshar K, Grunwald MR, Harrington C, Naik R, Cofrancesco J: Effect of the 2011 vs 2003 duty hour regulation-compliant models on sleep duration, trainee education, and continuity of patient care among internal medicine house staff: a randomized trial. JAMA Intern Med. 2013, 173: 649-655. 10.1001/jamainternmed.2013.2973.CrossRefPubMed Desai SV, Feldman L, Brown L, Dezube R, Yeh HC, Punjabi N, Afshar K, Grunwald MR, Harrington C, Naik R, Cofrancesco J: Effect of the 2011 vs 2003 duty hour regulation-compliant models on sleep duration, trainee education, and continuity of patient care among internal medicine house staff: a randomized trial. JAMA Intern Med. 2013, 173: 649-655. 10.1001/jamainternmed.2013.2973.CrossRefPubMed
35.
go back to reference Slankamenac K, Graf R, Puhan MA, Clavien PA: Perception of surgical complications among patients, nurses and physicians: a prospective cross-sectional survey. Patient Saf Surg. 2011, 5: 30-10.1186/1754-9493-5-30.PubMedCentralCrossRefPubMed Slankamenac K, Graf R, Puhan MA, Clavien PA: Perception of surgical complications among patients, nurses and physicians: a prospective cross-sectional survey. Patient Saf Surg. 2011, 5: 30-10.1186/1754-9493-5-30.PubMedCentralCrossRefPubMed
36.
go back to reference Randle J, Clarke M, Storr J: Hand hygiene compliance in healthcare workers. J Hosp Infect. 2006, 64: 205-9. 10.1016/j.jhin.2006.06.008.CrossRefPubMed Randle J, Clarke M, Storr J: Hand hygiene compliance in healthcare workers. J Hosp Infect. 2006, 64: 205-9. 10.1016/j.jhin.2006.06.008.CrossRefPubMed
37.
go back to reference Abdella NM, Tefera MA, Eredie AE, Landers TF, Malefia YD, Alene KA: Hand hygiene compliance and associated factors among health care providers in Gondar University Hospital, Gondar, North West Ethiopia. BMC Public Health. 2014, 14: 96-10.1186/1471-2458-14-96.PubMedCentralCrossRefPubMed Abdella NM, Tefera MA, Eredie AE, Landers TF, Malefia YD, Alene KA: Hand hygiene compliance and associated factors among health care providers in Gondar University Hospital, Gondar, North West Ethiopia. BMC Public Health. 2014, 14: 96-10.1186/1471-2458-14-96.PubMedCentralCrossRefPubMed
38.
go back to reference Salmon S, Tran HL, Bùi DP, Pittet D, McLaws ML: Beginning the journey of hand hygiene compliance monitoring at a 2,100-bed tertiary hospital in Vietnam. Am J Infect Control. 2014, 42: 71-73. 10.1016/j.ajic.2013.07.011.CrossRefPubMed Salmon S, Tran HL, Bùi DP, Pittet D, McLaws ML: Beginning the journey of hand hygiene compliance monitoring at a 2,100-bed tertiary hospital in Vietnam. Am J Infect Control. 2014, 42: 71-73. 10.1016/j.ajic.2013.07.011.CrossRefPubMed
39.
go back to reference Mauffrey C, Stahel PF: Shared decision making – The importance of open communication with our patients. Bone Joint J. 2013, 2: 2- Mauffrey C, Stahel PF: Shared decision making – The importance of open communication with our patients. Bone Joint J. 2013, 2: 2-
40.
41.
go back to reference Shah P, Cross V, Sii F: Sailing a safe ship: improving patient safety by enhancing the leadership skills of new consultant specialist surgeons. J Contin Educ Health Prof. 2013, 33: 190-200.PubMed Shah P, Cross V, Sii F: Sailing a safe ship: improving patient safety by enhancing the leadership skills of new consultant specialist surgeons. J Contin Educ Health Prof. 2013, 33: 190-200.PubMed
Metadata
Title
Current challenges and future perspectives for patient safety in surgery
Authors
Philip F Stahel
Cyril Mauffrey
Nathan Butler
Publication date
01-12-2014
Publisher
BioMed Central
Published in
Patient Safety in Surgery / Issue 1/2014
Electronic ISSN: 1754-9493
DOI
https://doi.org/10.1186/1754-9493-8-9

Other articles of this Issue 1/2014

Patient Safety in Surgery 1/2014 Go to the issue