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Three surgical safety steps
to protect patients |
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The HA's mission has always been to provide our patients with
safe, high-quality services. In June this year, three surgical safety steps were introduced to enhance our safety culture and risk management
in our operating theatres.
You can download a circular about these via the following path:
ha.home > Thematic View > Quality and Safety > Patient Safety
& Risk Management > Patient Safety Enhancement > Policy &
Guidelines. In addition, Dr Libby Lee, our Chief Manager (Patient
Safety and Risk Management), told HASLink more about them
during a recent interview.
Dr Lee says she and her colleagues in the HAHO Patient Safety and
Risk Management Team began drafting this surgical safety steps
circular at the end of 2008. They were supported in their task by
representatives from all the clusters and specialties, who actively
contributed ideas and opinions about the guiding principles and
details of surgical safety.
"Operating theatres in different hospitals have always had their
own safety procedures, including checking procedures," she
notes. "However, their details were very inconsistent. Our role
has therefore been to unify them by developing one series of clear
procedures that all our colleagues who work in operating theatres
can follow effectively."
Team checking by surgeons, anaesthetists and nurses
The World Health Organization (WHO) also regards surgical safety
as the second challenge, and it has addressed this by formulating
relevant guidelines and a checklist for the reference of healthcare
organisations around the world. |
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Dr Lee's team took note of the WHO guidelines while it was
consolidating the many views and ideas it had received from its
colleagues in cluster hospitals. They also gained the support from
representatives of various specialties. One subject it particularly
considered was what information should be checked, and when.
After in-depth discussion, it developed guidelines that it felt best
suited the needs of Hong Kong and the HA. These are based on a
concept of teamwork involving the three categories of healthcare
professionals who work in operating theatres, namely surgeons,
anaesthetists and nurses. |
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However, guidelines are still only guidelines. To be
useful and effective, they must be implemented by
people. "Our approach is for the three categories
of healthcare professionals β each of whom plays
a different role before, during and after surgery β
to work together in following the three steps of
surgical safety," explains Dr Lee.
"That means each category is responsible for
checking the items related to their own role, while
one colleague is responsible for co-ordinating the
entire process and leading the team in checking
key information, such as the patient's name and
identity card number."
To illustrate this principle more clearly, Dr Lee's
team has prepared a clever poster (right) that lists
the most important points that need to be checked,
as well as depicting a member of each professional
category. This serves to remind all our colleagues in
every category about the importance of teamwork
in surgical safety.
Quoting from WHO data, Dr Lee highlights the fact
that half of all the medical blunders that occur in
developed countries and which result in permanent
disability and death are related to surgical safety. Furthermore,
medical statistics reveal that implementing a three-step surgical
safety procedure can help to avoid a number of different types of
medical blunders, such as the wrong surgical site being marked
and medical consumables being left in the patient's body.
The Patient Safety and Risk Management Team plans to invite
colleagues from hospitals to express their views about ways to
improve the surgical safety policy further by attending a training
and sharing workshop it is organising on 5 and 6 November.
The way forward
As for the next steps, the Patient Safety and Risk Management
Team aims to introduce relevant checking guidelines for individual
specialties. "For example, our colleagues should check different
kinds of crucial information to safeguard patients who receive
endoscopy, cardiography and radiotherapy treatment." Last, but
not least, Dr Lee hopes to formulate similar mechanisms for use
when patients undergo intrusive procedures in hospital wards.
Although the three-step policy is only being used in operating
theatres at present, colleagues who work in other hospital
environments should also remember one of its key messages,
which is "time out". When undertaking each step of a complicated
medical task under considerable pressure, all of us should pause
for just a moment to check that we have done it in a satisfactory
way before we proceed to the next step. Let's strive together to
build up the safety culture and strengthen our risk-management
mechanisms!  |
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