Page 58 - 2022 Risk Basics - Surgical Practice

SVMIC Risk Basics: Surgical Practice

The surgical checklist was developed as an analogy to flight

crew checklists, which is a series of procedures performed
preliminary to takeoff that are intended to ensure safety during

flight operations. By extension, the concept of the “sterile

cockpit” has been introduced to describe protocols intended to
limit distraction during critical periods in the OR. One

important difference between the OR and the cockpit,
however, lies in the timing of critical events. They are much

more tightly concentrated during flight. In the OR, critical

events can and do occur throughout the operation.

When the timing of critical events, such as the clipping of an
intracranial aneurysm or the initiation of a cardiopulmonary

bypass, can be predicted, a structured communication protocol
should be implemented to reduce the risk of distraction and

miscommunication. The identification of critical phases of
surgery has been shown to reduce not only miscommunication

and distraction, but also operating time and costs.
6

Wrong Site & Timeouts

According to the most recent Joint Commission sentinel event
data, there were more than 3,300 sentinel events from 2015 to

2018; 440 were wrong-site surgeries. The promising data
7
revealed that after no decrease from 2015-2016, wrong-site

surgeries decreased from 121 to 104 in 2017 and decreased

further to 94 in 2018. In addition, the Pennsylvania Patient

6 Lee BT, Tobias AM, Yeuh JH, et al. Design and impact of an intraoperative pathway: A new operating room
model for team-based practice. J Am Coll Surg. 2008;207(6):865-873
7 Summary data of sentinel events reviewed by The Joint Commission.
https://www.jointcommission.org/assets/1/6/Summary_4Q_2018.pdf

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