Surgical Patient Care

This book focuses exclusively on the surgical patient and on the perioperative environment with its unique socio-technical and cultural issues. It covers preoperative, intraoperative, and postoperative processes and decision making and explores both sharp-end and latent factors contributing to harm and poor quality outcomes. It is intended to be a resource for all healthcare practitioners that interact with the surgical patient. This book provides a framework for understanding and addressing many of the organizational, technical, and cultural aspects of care to one of the most vulnerable patients in the system, the surgical patient. The first section presents foundational principles of safety science and related social science. The second exposes barriers to achieving optimal surgical outcomes and details the various errors and events that occur in the perioperative environment. The third section contains prescriptive and proactive tools and ways to eliminate errors and harm.The final section focuses on developing continuous quality improvement programs with an emphasis on safety and reliability. Surgical Patient Care: Improving Safety, Quality and Value targets an international audience which includes all hospital, ambulatory and clinic-based operating room personnel as well as healthcare administrators and managers, directors of risk management and patient safety, health services researchers, and individuals in higher education in the health professions. It is intended to provide both fundamental knowledge and practical information for those at the front line of patient care. The increasing interest in patient safety worldwide makes this a timely global topic. As such, the content is written for an international audience and contains materials from leading international authors who have implemented many successful programs.

Juan A. Sanchez, MD, MPAAssociate Professor of SurgeryJohns Hopkins University School of MedicineChair of Surgery, Saint Agnes Hospital900 Caton AvenueBaltimore, MD USAPaul Barach, BSc, MD, MPHClinical ProfessorChildren-s Hospital of Michigan Wayne State University School of MedicineDetroit, MI USAJulie K. Johnson, MSPH, PhDProfessorNorthwestern UniversityDepartment of SurgeryChicago, IL USA Jeffrey P. Jacobs, MD, FACS, FACC, FCCP Professor of Surgery, Johns Hopkins UniversityDirector, Andrews/Daicoff Cardiovascular ProgramSurgical Director of Heart Transplantation and Extracorporeal Life Support ProgramsJohns Hopkins All Children-s Heart InstituteAll Children-s HospitalSaint Petersburg, FLUSA

Surgical Patient Care: Improving Safety, Quality and Value
 
Editors:
Juan A. Sanchez, MD Paul Barach, MD Julie K. Johnson, PhD Jeffrey P. Jacobs, MD
 
Table of Contents
 
 
Section I. Fundamentals of Systems and Safety Science
 
Chapter 1 - The Burning Platform: Improving Surgical Quality and Keeping Patients Safe - Juan A. Sanchez and Kevin W. Lobdell
 
Chapter 2 - Risk factors and epidemiology of Surgical Safety - Oliver Groene
 
Chapter 3 - Concepts and Models of Safety, Resilience, and Reliability - Jonathan Gao and Sidney Dekker
 
Chapter 4 - Surgery through a human factors and ergonomics lens - Ken Catchpole
 
Chapter 5 - The Relationship between Teamwork and Patient Safety - Sallie J. Weaver, Lauren E. Benishek, Ira Leeds and Elizabeth C. Wick
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Chapter 6 - Enterprise and Human Factors Risk Management in Healthcare - James M. Levett, James M. Fasone, Anngail Levick Smith, Stanley S. Labovitz, Jennifer Labovitz, Susan Mellott and Douglas B. Dotan
 
Chapter 7 - The Patient Experience: an Essential Component of High-Value Care and Service - Sara Shaunfield, Timothy Pearman and Dave Cella
 
Chapter 8 - Patients and Families as Co-Producers of Safe and Reliable Outcomes - Helen Haskell and Tanya Lord
 
Chapter 9 - Tools and Strategies for Continuous Quality Improvement and Patient Safety - Julie K. Johnson and Paul Barach
 
Chapter 10 - New Surgical Technology Implementation and Patient Safety - Chandler D. Wilfong and Steven D. Schwaitzberg
 
 
Section II - Job and Organizational Design
 
Chapter 11 - Organizational Learning and Cultural Determinants of Safety - Kathleen M. Sutcliffe
 
Chapter 12 - The role of architecture and physical environment in Hospital Safety Design - Charles D. Cadenhead, Laurie Waggener and Bhargav Goswami
 
Chapter 13 - Building Surgical Expertise through the Science of Continuous Learning and Training - Peter Hani Cosman, Pramudith Sirimanna and Paul Barach
 
Chapter 14 - Promoting Occupational Wellness and Combating Professional Burnout in the Surgical Workforce - Ross M. Ungerleider, Jamie Dickey Ungerleider and Graham D. Ungerleider
 
Chapter 15 - Executive Leadership and Surgical Quality: A Guide for Senior Hospital Leaders - Susan Moffatt-Bruce and Robert Higgins
 
Chapter 16 - Information Technology Infrastructure, Management and Implementation: The Rise of the Emergent Clinical Information System and the Chief Medical Information Officer - Jon David Patrick, Paul Barach and Ali Besiso
 
Chapter 17 - Redesigning Hospital Alarms for Reliable and Safe Care - Paul Barach and Juan A. Sanchez
 
Chapter 18 - Implementation Science: Translating Research into Practice for Sustained Impact - Gregory A. Aarons, Marisa Sklar and Nick Sevdalis
 
 
Section III - Perioperative Quality and Patient Safety
 
Chapter 19 - The Leadership Role: Designing Perioperative Surgical Services for Safety and Efficiency - Victoria M. Steelman and Martha D. Stratton
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Chapter 20 - Operating Room Management, Measures of OR Efficiency and Cost Effectiveness - Sanjana Vig, Bassam Kadry and Alex Macario
 
Chapter 21 - The Science of Delivering Safe and Reliable Anesthesia Care - Maurice F. Joyce, Holly E. Careskey, Paul Barach and Ruben J. Azocar
 
Chapter 22 - Enhanced Recovery After Surgery: ERAS - Jonas Nygren, Olle Ljungqvist and Anders Thorell
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Chapter 23 - The Next Frontier: Ambulatory and Outpatient Surgical Safety and Quality - Beverly A. Kirchner
 
Chapter 24 - Human Factors and Operating Room Design Challenges - Dirk de Korne, Loh Huey Peng and Shanqing Yin
 
Chapter 25 - Diagnostic Error in Surgery and Surgical Services - Mark L. Graber, Juan A. Sanchez and Paul Barach
 
Chapter 26 - Preventing Perioperative `Never Events- - Patricia C. Seifert, Paula Graling and Juan A. Sanchez
 
Chapter 27 - Health Care Associated Infections in Surgical Practice - Scott J. Ellner and Affan Umer
 
Chapter 28 - Safer Medication Administration Through Design and Ergonomics - Sheldon S. Sones and Paul Barach
 
Chapter 29 - Preventing Venous Thromboembolism Across the Surgical Care Continuum - Lisa M. Kodadek and Elliott R. Haut
 
Chapter 30 - Preventing Perioperative Positioning and Equipment Injuries - Lisa Spruce
 
Chapter 31 - Challenges in Preventing Electrical, Thermal, and Radiation Injuries - Mark E. Bruley
 
Chapter 32 - Improving Clinical Performance by Analyzing surgical skills and operative errors - Katherine E. Law, Anne-Lise D. D-Angelo, Elaine R. Cohen and Carla M. Pugh
 
 
Section IV - Approaches to Managing Risks
 
Chapter 33 - Perioperative Risk and Management of Surgical patients - James M. Levett, Susan Mellott, Anngail Levick Smith, James M. Fasone, Stanley S. Labovitz, Jennifer Labovitz and Douglas B. Dotan
 
Chapter 34 - Managing the Complex High-Risk Surgical Patient - Kevin W. Lobdell, B. Todd Heniford and Juan A. Sanchez
 
Chapter 35 - Geriatric Surgical Quality and Wellness - Daniel J. Gallante, JoAnn Coleman and Mark R. Katlic
 
Chapter 36 - Patient Transitions and Handovers across the Continuum of Surgical Care - Donna M. Woods and Lisa M. McElroy
 
Chapter 37 - Failure to Rescue and Failure to Perceive Patients in Crisis - Christian Peter Subbe and Paul Barach
 
Chapter 38 - A Quiet Revolution: Communicating and disclosing about unexpected outcomes and Resolving Patient Harm - William M. Sage, Madelene J. Ottosen and Ben Coopwood
 
Chapter 39 - It-s My Fault: Personal Accountability & the Role of the Risk Manager in Creating Patient Safety - Elizabeth A. Duthie
 
Chapter 40 - Capturing, Reporting and Learning from Adverse Events - Juan A. Sanchez and Paul Barach
 
Chapter 41 - How not to run an incident investigation - Bryce R. Cassin and Paul Barach
 
Chapter 42 - Multi-institutional Learning and Collaboration to Improve Quality and Safety - Julie K. Johnson, Christina A. Minami, Allison R. Dahlke and Karl Y. Bilimoria  
Chapter 43 - Lessons Learned from Anesthesia Registries About Surgical Safety and Reliability - Richard P. Dutton
 
Chapter 44 - Use of Surgical Registry Data to Improve Outcomes - Jeffrey P. Jacobs
 
 
Section V - Regulation, Policy, and the Future of Surgical Care
 
Chapter 45 - How regulators assess safety and quality in surgical services - Stephen Leyshon, Tita Listyowardojo Bach, Eva Turk, Aileen Orr, Bobbie N. Ray-Sannerud and Paul Barach
 
Chapter 46 - The Perioperative Surgical Home: The New Frontier - Juhan Paiste, Daniel I. Chu and Thomas R. Vetter
 
Chapter 47 - Surgical Medical Education Program Accreditation and the Clinical Learning Environment: Patient Safety and Healthcare Quality - John R. Potts, III, Constance K. Haan and Kevin B. Weiss
 
Chapter 48 - Affordable Care Act, Public Legislation and Professional Self-Regulation: Implications for Public Policy - Stephen J. Lahey
 
Chapter 49 - Maintaining Surgical Safety and Quality in Rural and Remote Settings - Amy L. Halverson and Julie K. Johnson
 
Chapter 50 - Global Surgery: Progress and challenges in Surgical Quality and Patient Safety - Christopher Pettengell, Stephen Williams and Ara Darzi
 
Chapter 51 - International Perspectives on Safety, Quality and Reliability of Surgical Care - Sertaç Çiçek and Hi-am Alahdab
 
Chapter 52 - Surgical Safety in Developing Countries: Middle East, North Africa and Gulf Countries - Abdulelah Alhawsawi and Paul Barach
 
Chapter 53 - Future Directions of Surgical Safety - Timothy D. Browder and Paul M. Maggio