The American surgeon
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There is an increasing demand for interventions to improve patient safety, but there is limited data to guide such reform. In particular, because much of the existing research is outcome-driven, we have a limited understanding of the factors and process variations that influence safety in the operating room. ⋯ Next, we provide an introduction to techniques that can be used to understand safety at the point of care and we review the data that exists relating such studies to improved outcomes. Future work in this area will need to prospectively study the processes and factors that impact patient safety and vulnerability in the operating room.
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The American surgeon · Nov 2006
ReviewThe challenge of changing roles and improving surgical care now: Crew Resource Management approach.
Many surgeons are also pilots; the two activities demand similar skill sets. Surgeons have developed an interest in aviation models for managing risk and reducing adverse events, such as Crew Resource Management training. ⋯ Each suggestion is offered based on the value added to aviation, with an acknowledgment that the suggestion may be more or less applicable in surgery. The suggestions for dealing with the changing roles for surgeons are: Crew Resource Management-type training to improve teamwork should be required for hospital credentialing, surgeons should brief the operating room team before an operation, surgeons should write standards specific to their organization, surgeons should recognize fatigue and age as factors in performance, surgeons should have "check-rides" as a part of the credentialing process, surgeons should abandon the mortality and morbidity conference in favor of a data collection system that effectively examines adverse events for root causes of error, and all members of the surgical team should be subject to mandatory, random drug testing.
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The American surgeon · Nov 2006
Multicenter StudyThe hazards of using administrative data to measure surgical quality.
Administrative claims data have been used to measure risk-adjusted clinical outcomes of hospitalized patients. These data have been criticized because they cannot differentiate risk factors present at the time of admission from complications that occur during hospitalization. This paper illustrates how valid risk-adjustment can be achieved by enhancing administrative data with a present-on-admission code, admission laboratory data, and admission vital signs. ⋯ Use of only administrative data resulted in unacceptable amounts of systematic bias in 24 per cent of hospitals for craniotomy and 19 per cent of hospitals for postoperative sepsis. Addition of a present-on-admission code, laboratory data, and vital signs reduced the percentage of hospitals with unacceptable bias to two percent both for craniotomy and for postoperative sepsis. These illustrations demonstrate suboptimal risk stratification with administrative claims data only, but show that present-on-admission coding combined with readily available laboratory data and vital signs can support accurate risk-adjustment for the assessment of surgical outcomes.
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Multiple studies support the intuitive association between higher provider procedure volume and better clinical outcomes. Health care purchasers and payers have been seeking ways to direct patients to high-volume providers to improve the quality of care received and to avoid costs associated with higher surgical morbidity. ⋯ Furthermore, a policy of volume-based referral does not address surgical quality directly, is applicable to only a very small segment of surgical care, and is logistically problematic. However, in the absence of viable alternative measures of surgical quality, imperfect proxies such as volume will likely continue to be a significant part of the national dialogue surrounding surgical quality.
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The American surgeon · Nov 2006
ReviewSafety, quality, and the National Surgical Quality Improvement Program.
The Institute of Medicine 1999 publication, To Err is Human, focused attention on preventable provider errors in surgery, and prompted numerous new national initiatives to improve patient safety. It is uncertain whether these initiatives have actually improved patient safety, mainly because of the lack of a quantitative metric for the assessment of patient safety in surgery. A 15-year experience with the National Surgical Quality Improvement Program, which originated in the Veteran's Administration in 1991 and was recently made available to the private sector, prompts the surgical community to place patient safety in surgery within a much larger conceptual framework than that of the Institute of Medicine report, and provides a quantitative metric for the assessment of patient safety initiatives. This conceptual framework defines patient safety in surgery as safety from all adverse outcomes (not only preventable errors and sentinel events); regards safety as an integral part of quality of surgical care; recognizes that adverse outcomes, and hence patient safety, are primarily determined by quality of systems of care; and uses comparative risk-adjusted outcome data as a metric for the identification of system problems and for the assessment and improvement of patient safety from adverse outcomes.