Review the evidence regarding methods to prevent wrong site operations and present a framework that healthcare organizations can use to evaluate whether they have reduced the probability of wrong site, wrong procedure, and wrong patient operations.
Operations involving the wrong site, patient, and procedure continue despite national efforts by regulators and professional organizations. Little is known about effective policies to reduce these "never events," and healthcare professional's knowledge or appropriate use of these policies to mitigate events.
A literature review of the evidence was performed using PubMed and Google; key words used were wrong site surgery, wrong side surgery, wrong patient surgery, and wrong procedure surgery. The framework to evaluate safety includes assessing if a behaviorally specific policy or procedure exists, whether staff knows about the policy, and whether the policy is being used appropriately.
Higher-level policies or programs have been implemented by the American Academy of Orthopaedic Surgery, Joint Commission on Accreditation of Healthcare Organizations, Veteran's Health Administration, Canadian Orthopaedic, and the North American Spine Society Associations to reduce wrong site surgery. No scientific evidence is available to guide hospitals in evaluating whether they have an effective policy, and whether staff know of the policy and appropriately use the policy to prevent "never events."
There is limited evidence of behavioral interventions to reduce wrong site, patient, and surgical procedures. We have outlined a framework of measures that healthcare organizations can use to start evaluating whether they have reduced adverse events in operations.
To provide guidelines for antimicrobial prophylaxis on the basis of the type of surgical procedure.
Standard drug regimens for prophylaxis of infection in a variety of surgical procedures were considered, including a first-generation cephalosporin; an aminoglycoside in combination with metronidazole, clindamycin or erythromycin; a second-generation cephalosporin; and trimethoprim-sulfamethoxazole.
In order of importance: efficacy, side effects and cost.
A MEDLINE search of articles published between January 1980 and December 1991. For clinical trial data, greatest emphasis was placed on randomized, double-blind studies using appropriate controls.
The Committee on Antimicrobial Agents of the Canadian Infectious Disease Society (CIDS) and two recognized experts (T.K.W. and O.D.R.) recommended antimicrobial regimens suitable for prophylaxis of infections in surgery. Whenever possible, recommendations were based on data from randomized controlled trials.
Implementation of the guidelines is expected to reduce the incidence of postoperative infections, the inappropriate use of antibiotics and costs to hospitals.
Antibiotic prophylaxis is recommended for operations with a high risk of postoperative wound infection or with a low risk of infection but significant consequences if infection occurs. These operations include clean-contaminated procedures and certain clean procedures. Drugs should be administered intravenously immediately before the operation. In colorectal operations oral administration also appears to be effective. A single dose is sufficient for most procedures. The regimen chosen depends on the pathogens usually associated with wound infection in a given operation, the serum half-life of the drugs, the antimicrobial susceptibility patterns in the local hospital and the cost of the drugs.
The guidelines were compared with others in standard textbooks of surgery and peer-reviewed articles. The guidelines were prepared and revised by the Committee on Antimicrobial Agents of the CIDS. They were then reviewed and revised further by the Council of the CIDS.
The CIDS was solely responsible for developing, funding and endorsing these guidelines.
Research on adverse outcomes following common surgical procedures has suggested the importance of hospital and surgeon variables. Policy directions depend on which factors are important in influencing patient outcomes and what sorts of policies are feasible. Focusing on where a given procedure is performed highlights a concern for centralization; emphasizing who should perform a particular operation implies physician certification. Finally, monitoring involves identifying particular hospitals that appear to have relatively poor (or relatively good) results. This paper analyzes patient, surgeon, and hospital characteristics associated with serious postdischarge complications of hysterectomy, cholecystectomy, and prostatectomy in patients age 25 and over in Manitoba, Canada, following surgery during 1974 through 1976. The three procedures differ markedly in the ease of prediction of the probability of complications and in the predictive importance of patient, hospital, and physician variables. The predictors worked fairly well for cholecystectomy, somewhat less well for hysterectomy, and not well at all for prostatectomy. Hospital variables were not generally important in the multiple logistic regressions. After controlling for case mix and type of surgery, physician surgical experience was found to account for relatively large differences (almost two to one) in the probability of patient complications following cholecystectomy. Cholecystectomy might be a candidate for certification because of the epidemiology of the operation. As of the mid-1970s, a substantial proportion of the cholecystectomies were being performed by physicians with comparatively little ongoing experience with this type of procedure. Moreover, a monitoring perspective identified one hospital with a significantly higher postcholecystectomy complication rate, even after physician experience was taken into account. Both identifying which procedures should be attended to and focusing on problems following surgery are important beyond Manitoba and highly relevant to such American requirements as Peer Review Organizations. Methods of increasing the efficiency of using claims data for quality assurance studies are outlined.
Because in chronic purulent epitympanitis pyodestruction affects bone tissues with resultant chronic osteomyelitis of the temporal bone it is thought necessary to remove radically all the foci of chronic inflammation and to open all the compartments of the middle ear in any operation for epitympanitis. This is also relevant to operations performed to create a small trepanation cavity or new sound conduction system.
The effective management of wait times is a top priority for Canadians. Attention to date has largely focused on wait times for adult surgery. The purpose of this study was to develop surgical wait time access targets for children.
Using nominal group techniques, expert panels reached consensus on prioritization levels for 574 diagnoses in 10 surgical disciplines for wait 1 (W1; time from primary care visit to surgical consultation) and wait 2 (W2; time from decision to operate to receipt of surgery).
A 7-stage priority classification reflects the permissible timeframe for children to receive consultation (W1) or surgery (W2). Access targets by priority were linked to 574 diagnoses in 10 pediatric surgical subspecialties.
The pediatric surgical wait time access targets are a standardized, comprehensive and consensus-based model that can be systematically applied to children's hospitals across Canada. Future research and evaluation on outcomes from this model will evaluate improved access to pediatric surgical care.
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Laparoscopic technique for groin hernia surgery has been used increasingly in Denmark during the latest ten years. This tendency is in accordance with both national and international guidelines, which recommend either laparoscopic repair or open repair ad modum Lichtenstein. The surgical training in Denmark has not kept up with this development, and in the surgical curriculum there is a lack of organized training in laparoscopic inguinal hernia surgery. This article discusses this discrepancy and suggests solutions to help solving the problems.