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45 | Patient Safety |
Tinsay A. Woreta and Martin A. Makary |
A patient develops a wound infection following a femoral-popliteal bypass with a prosthetic graft. Root-cause analysis identifies that the surgeon forgot to order perioperative antibiotics. How could this problem have been prevented?
Redesigning hospital systems to include standardized checks and prompts, such as prewritten orders, is increasingly being recognized as a way to maintain high standards of surgical care.
Systems Approach to Patient Safety
•An approach to increasing the quality of medical care by improving hospital systems
•Emphasizes teamwork, communication, and standardized checks
•Views medical errors as the consequence of faults in various systems
Innovative hospital systems, including preoperative briefings and checklists to streamline delivery of care, are associated with improved surgical outcomes.
A hospital claims that their surgical site infection rate is lower than the national average. What process of quality measurement provides standard benchmarks for participating departments of surgery?
The National Surgical Quality Improvement Program (NSQIP) is a standardized system for measuring adverse events using a risk adjustment method.
National Surgical Quality Improvement Program
•Patient data is entered into a national database for benchmarking
•Data is reported back as an observed-to-expected ratio for complications
•Participating hospitals see their outcomes relative to the national average
•Uses standardized definitions of preoperative morbidity and surgical complications
After a routine carotid endarterectomy for carotid artery stenosis, the patient suffers a cerebrovascular accident. This complication would be classified as what type of event?
This event is an “adverse event” because the patient experienced an injury as a result of medical management.
•Injury caused by medical management rather than the underlying condition of the patient
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