Patient safety for the surgical trainee

This article highlights some key principles in patient safety for the surgical trainee. The incidence of harm in healthcare and surgical practice in particular are outlined. The importance of clinical human factors is highlighted along with how this discipline has helped healthcare workers improve t...

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Published inSurgery (Oxford) Vol. 39; no. 12; pp. 816 - 828
Main Author Paisley, Anna M
Format Journal Article
LanguageEnglish
Published Elsevier Ltd 01.12.2021
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Abstract This article highlights some key principles in patient safety for the surgical trainee. The incidence of harm in healthcare and surgical practice in particular are outlined. The importance of clinical human factors is highlighted along with how this discipline has helped healthcare workers improve the care they provide to patients. Concepts of systems thinking are introduced; patient harm rarely comes from the isolated action of an individual but from deficiencies in the systems of which they are a part and with which they interact. The shifting paradigm of patient safety thinking is highlighted’ with an increasing focus on reducing risk (safety II) rather than eliminating harm (safety I). Strategies for recording, analysing and learning from patient harms are discussed. Examples are provided of commonly used systems models to help clinicians in this area. A number of strategies that have been developed to enhance safety, trap errors and mitigate potential harm to surgical patients are discussed. Information is provided on several key national and international patient safety initiatives that have been instrumental in enhancing patient care by disseminating learning and collaboration between individual units, hospitals and health services.
AbstractList This article highlights some key principles in patient safety for the surgical trainee. The incidence of harm in healthcare and surgical practice in particular are outlined. The importance of clinical human factors is highlighted along with how this discipline has helped healthcare workers improve the care they provide to patients. Concepts of systems thinking are introduced; patient harm rarely comes from the isolated action of an individual but from deficiencies in the systems of which they are a part and with which they interact. The shifting paradigm of patient safety thinking is highlighted’ with an increasing focus on reducing risk (safety II) rather than eliminating harm (safety I). Strategies for recording, analysing and learning from patient harms are discussed. Examples are provided of commonly used systems models to help clinicians in this area. A number of strategies that have been developed to enhance safety, trap errors and mitigate potential harm to surgical patients are discussed. Information is provided on several key national and international patient safety initiatives that have been instrumental in enhancing patient care by disseminating learning and collaboration between individual units, hospitals and health services.
Author Paisley, Anna M
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  organization: Anna M Paisley BM BCh MA DM FRCSEd (Gen.Surg) FFSTEd is Chair, Patient Safety Group, Royal College of Surgeons, Edinburgh; and a Consultant General and Oesophagogastric Surgeon at the Royal Infirmary, Edinburgh, UK. Conflict of Interests: none declared
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Cites_doi 10.1136/bmjqs-2013-002757
10.1056/NEJMsa0810119
10.1136/bmj.320.7237.768
10.1002/bjs.10779
10.1016/j.surg.2005.06.017
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10.1056/NEJM199102073240604
10.1136/bmjqs-2013-001812
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Issue 12
Keywords brief
systems thinking
patient safety
Adverse events
clinical human factors
high-risk organizations
safety culture
debrief
non-technical skills
surgical safety checklist
surgery
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References Yule, Gupta, Gazarian (bib6) 2018; 105
(bib15) 2008
Yule, Flin, Paterson-Brown, Maran (bib5) 2006; 139
Brennan, Leape, Laird (bib1) 1991; 324
Haynes, Weiser, Berry (bib12) 2009; 360
(bib11) December 2010
(bib2) 2000
Reason (bib9) 2000; 320
Carayon, Xie, Kianfar (bib4) 2014; 23
(bib3) 2000
Hollnagel (bib7) 2014
Carayon, Hundt, Karsh (bib10) 2006; 15
(bib13) 2019
Vincent, Burnett, Carthey (bib8) 2014; 23
(bib14) 2019
(10.1016/j.mpsur.2021.09.005_bib15) 2008
Carayon (10.1016/j.mpsur.2021.09.005_bib4) 2014; 23
Hollnagel (10.1016/j.mpsur.2021.09.005_bib7) 2014
Carayon (10.1016/j.mpsur.2021.09.005_bib10) 2006; 15
Yule (10.1016/j.mpsur.2021.09.005_bib6) 2018; 105
(10.1016/j.mpsur.2021.09.005_bib11) 2010
Yule (10.1016/j.mpsur.2021.09.005_bib5) 2006; 139
Vincent (10.1016/j.mpsur.2021.09.005_bib8) 2014; 23
Brennan (10.1016/j.mpsur.2021.09.005_bib1) 1991; 324
(10.1016/j.mpsur.2021.09.005_bib2) 2000
(10.1016/j.mpsur.2021.09.005_bib13) 2019
Haynes (10.1016/j.mpsur.2021.09.005_bib12) 2009; 360
(10.1016/j.mpsur.2021.09.005_bib3) 2000
Reason (10.1016/j.mpsur.2021.09.005_bib9) 2000; 320
(10.1016/j.mpsur.2021.09.005_bib14) 2019
References_xml – year: 2008
  ident: bib15
  article-title: Guidelines for safe surgery: safe surgery saves lives
– volume: 23
  start-page: 670
  year: 2014
  end-page: 677
  ident: bib8
  article-title: Safety measurement and monitoring in healthcare: a framework to guide clinical teams and healthcare organisations in maintaining safety
  publication-title: BMJ Qual Saf
  contributor:
    fullname: Carthey
– year: 2000
  ident: bib2
  publication-title: To err is human: building a safer health system
– year: 2019
  ident: bib14
  article-title: Fifth patient report of the National Emergency Laparotomy Audit RCoA London
– volume: 105
  start-page: 719
  year: 2018
  end-page: 727
  ident: bib6
  article-title: Construct and criterion validity testing of the Non-Technical Skills for Surgeons (NOTSS) behaviour assessment tool using videos of simulated operations
  publication-title: BJS
  contributor:
    fullname: Gazarian
– volume: 15
  start-page: i50
  year: 2006
  end-page: i58
  ident: bib10
  article-title: Work system design for patient safety: the SEIPS model
  publication-title: Qual Saf Health Care
  contributor:
    fullname: Karsh
– volume: 320
  start-page: 768
  year: 2000
  end-page: 770
  ident: bib9
  article-title: Human error: models and management
  publication-title: BMJ
  contributor:
    fullname: Reason
– year: 2014
  ident: bib7
  article-title: Safety-I and Safety-II; the past and future of safety management
  contributor:
    fullname: Hollnagel
– volume: 139
  start-page: 140
  year: 2006
  end-page: 149
  ident: bib5
  article-title: Non-technical skills for surgeons: a review of the literature
  publication-title: Surgery
  contributor:
    fullname: Maran
– volume: 324
  start-page: 370
  year: 1991
  end-page: 376
  ident: bib1
  article-title: Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I
  publication-title: N Engl J Med
  contributor:
    fullname: Laird
– year: December 2010
  ident: bib11
  article-title: ‘How to Guide’. Five Steps to Safer Surgery
– year: 2019
  ident: bib13
  article-title: The NHS Patient Safety Strategy. Safer culture, safer systems, safer patients
– volume: 23
  start-page: 196
  year: 2014
  end-page: 205
  ident: bib4
  article-title: Human Factors and ergonomics as a patient safety practice
  publication-title: BMJ Qual Saf
  contributor:
    fullname: Kianfar
– volume: 360
  start-page: 491
  year: 2009
  end-page: 499
  ident: bib12
  article-title: A surgical safety checklist to reduce morbidity and mortality in a global population
  publication-title: New Engl J Med
  contributor:
    fullname: Berry
– year: 2000
  ident: bib3
  article-title: An organisation with a memory: report of an expert group on learning from adverse events in the NHS. Chaired by the Chief Medical Officer
– volume: 23
  start-page: 670
  year: 2014
  ident: 10.1016/j.mpsur.2021.09.005_bib8
  article-title: Safety measurement and monitoring in healthcare: a framework to guide clinical teams and healthcare organisations in maintaining safety
  publication-title: BMJ Qual Saf
  doi: 10.1136/bmjqs-2013-002757
  contributor:
    fullname: Vincent
– year: 2008
  ident: 10.1016/j.mpsur.2021.09.005_bib15
– year: 2019
  ident: 10.1016/j.mpsur.2021.09.005_bib13
– year: 2000
  ident: 10.1016/j.mpsur.2021.09.005_bib3
– year: 2014
  ident: 10.1016/j.mpsur.2021.09.005_bib7
  contributor:
    fullname: Hollnagel
– year: 2010
  ident: 10.1016/j.mpsur.2021.09.005_bib11
– volume: 360
  start-page: 491
  year: 2009
  ident: 10.1016/j.mpsur.2021.09.005_bib12
  article-title: A surgical safety checklist to reduce morbidity and mortality in a global population
  publication-title: New Engl J Med
  doi: 10.1056/NEJMsa0810119
  contributor:
    fullname: Haynes
– volume: 320
  start-page: 768
  year: 2000
  ident: 10.1016/j.mpsur.2021.09.005_bib9
  article-title: Human error: models and management
  publication-title: BMJ
  doi: 10.1136/bmj.320.7237.768
  contributor:
    fullname: Reason
– volume: 105
  start-page: 719
  year: 2018
  ident: 10.1016/j.mpsur.2021.09.005_bib6
  article-title: Construct and criterion validity testing of the Non-Technical Skills for Surgeons (NOTSS) behaviour assessment tool using videos of simulated operations
  publication-title: BJS
  doi: 10.1002/bjs.10779
  contributor:
    fullname: Yule
– volume: 139
  start-page: 140
  year: 2006
  ident: 10.1016/j.mpsur.2021.09.005_bib5
  article-title: Non-technical skills for surgeons: a review of the literature
  publication-title: Surgery
  doi: 10.1016/j.surg.2005.06.017
  contributor:
    fullname: Yule
– volume: 15
  start-page: i50
  issue: suppl 1
  year: 2006
  ident: 10.1016/j.mpsur.2021.09.005_bib10
  article-title: Work system design for patient safety: the SEIPS model
  publication-title: Qual Saf Health Care
  doi: 10.1136/qshc.2005.015842
  contributor:
    fullname: Carayon
– year: 2019
  ident: 10.1016/j.mpsur.2021.09.005_bib14
– volume: 324
  start-page: 370
  year: 1991
  ident: 10.1016/j.mpsur.2021.09.005_bib1
  article-title: Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I
  publication-title: N Engl J Med
  doi: 10.1056/NEJM199102073240604
  contributor:
    fullname: Brennan
– year: 2000
  ident: 10.1016/j.mpsur.2021.09.005_bib2
– volume: 23
  start-page: 196
  year: 2014
  ident: 10.1016/j.mpsur.2021.09.005_bib4
  article-title: Human Factors and ergonomics as a patient safety practice
  publication-title: BMJ Qual Saf
  doi: 10.1136/bmjqs-2013-001812
  contributor:
    fullname: Carayon
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SubjectTerms Adverse events
brief
clinical human factors
debrief
high-risk organizations
non-technical skills
patient safety
safety culture
surgery
surgical safety checklist
systems thinking
Title Patient safety for the surgical trainee
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