The Ethical Perspective
“When patients die in other areas of medicine the question is ‘what happened?’ However, when a patient dies during or after surgery, the question is, ‘what did you do?’”—Peter Angelos…
Compliance to Patient Safety Culture
Fig. 13.1 Department of Health and Human Services organizational chart [7] The federal government works in partnership with state and local agencies, national quality and safety organizations, accrediting organizations, insurers…
Surgical Safety Checklists
Fig. 25.1 Errors (incidents) are not the same as adverse events. Only a part of all adverse events are preventable Every undesired outcome of care is a complication, irrespective of…
Postoperative Monitoring for Clinical Deterioration
Fig. 8.1 Oxyhemoglobin dissociation curve Conventional Wisdom Can Be Harmful The Oxyhemoglobin Dissociation Curve (ODC), discovered in 1903 by Christian Bohr, was changed substantially in the mid 1980s because of…
Research and Patient Safety
Fig. 20.1 Surgery and research as the best advocates for patient safety. GCP good clinical practice, GLP good lab practice Traditional surgical research has covered a vast amount of peri-operative…
The Surgery Morbidity and Mortality Conference
Old New (2011) Preventable Unanticipated mortality with opportunity for improvement Non-Preventable Mortality without opportunity for improvement Possibly Preventable Anticipated mortality with opportunity for improvement The Institute of Medicine in 1999…
Improving Operating Room Safety: A Success Story
Fig. 31.1 Operating room efficiencies study. These are the results of our local operating room efficiency study. The x axis is the issues studied. The y axis is the frequency…
Disclosure of Complications
Organisation Guideline American Medical Association When “a patient suffers significant medical complications that may have resulted from the doctor’s mistake . . . the doctor is ethically required to inform…
The Universal Protocol: Pitfalls and Pearls
Surgical “never-events” 1. Surgery performed on the wrong body part. 2. Surgery performed on the wrong patient. 3. Wrong surgical procedure performed on a patient. 4. Unintended retention of a…
Reporting of Complications
Fig. 22.1 Article accesses to the open-access journal Patient Safety in Surgery. The graph shows the growing number of accesses to articles published from the time of the journal’s launch…
