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Perioperative harm in New ZealandSince inception, the New Zealand Health Quality & Safety Commission (the Commission) has been particularly interested in the reduction of perioperative harm in our operating rooms (ORs). New Zealand appears to have a relatively high rate of perioperative adverse events. OECD data from 2012/13 suggested New Zealand had one of the highest documented rates of postoperative sepsis (1,260 per 100,000 hospital discharges in 2012/2013), the third highest rate of foreign bodies left in during a procedure (10.8 per 100,000 discharges), and was six countries behind the average for pulmonary embolism and deep vein thrombosis (PE and DVT), with a crude rate of 912 per 100,000 discharges. Only four OECD countries reported worse rates.1Some argue that we are simply better at recording adverse outcomes, but regardless, these numbers are unacceptable. The Commissions Safe Surgery NZ programme was set up specifically to improve this situation through promulgation of several evidence-based interventions, including the World Health Organization (WHO) Surgical Safety Checklist, surgical team briefings and debriefings, and effective venous thromboembolism prophylaxis. These formed the backbone of the recent focus on reducing perioperative harmin the Open for Better Care campaign. This article provides background and context to this work, and a discussion of the evolution of perioperative care in New Zealand.WHO Surgical Safety ChecklistFigure 1:World Alliance for Patient Safetys Ten Objectives for Safe SurgeryThe WHO Surgical Safety Checklist (the Checklist) is an evidence-based 19-item tool designed to improve patient outcomes by reducing error and improving teamwork and communication in the OR. The World Alliance for Patient Safety, recognising the unacceptably high rate of perioperative morbidity and mortality, identified ten universal objectives for safe surgery (see Figure 1) through consultative work in its second global challenge, the Safe Surgery Saves Lives initiative.2 These objectives were underpinned by an appreciation of the importance of teamwork in achieving good outcomes for patients undergoing surgery.The success of checklists in high-reliability organisations such as aviation, the military, and nuclear power, as well as in central line infections,3,4 inspired the development of this tool (see Figure 2) to help achieve these objectives. From the outset, the Checklist was designed to improve teamwork, communication and culture in addition to facilitating certain important checks,5,6 and there is increasing evidence that its effective use can achieve all of these things.7-10Figure 2: Surgical Safety Checklist (Australia and New Zealand) The University of Auckland and Auckland City Hospital collaborated as one of the eight international sites in the initial evaluation of the Checklist; introducing the Checklist was associated with substantial reductions in perioperative mortality (from 1.5% to 0.8%), and complications (from 11% to 7%).11Numerous studies have supplemented these initial findings,6,10,12-14 and results have been integrated into two systematic reviews.15,16 Some extended the scope of the intervention, but collectively they provide considerable support for training, briefings (see below), and other initiatives aligned with the Checklist in promoting teamwork, communication, and safety. The Netherlands Surgical Patient Safety System (SURPASS), for example, found a significant reduction in in-hospital mortality (1.5% to 0.8%) and in overall complications (27.3 to 16.7 per 100) after implementation of a comprehensive surgical checklist.17 More recently, a stepped-wedge cluster randomised controlled trial showed a reduction in complications from 19.9% to 11.5% with the use of the Checklist, giving an absolute risk reduction of 8.4. Length of stay decreased by 0.8 days, and mortality was significantly decreased in one of the two study centres, but not the other.18 Semel et al found its use reduced cost as well as harm,19 and a New Zealand analysis has suggested it will provide an annual steady state benefit of NZD 5.7 million to our health system, primarily through avoided complications of surgical care.20The introduction of the Checklist has not come without its challenges. Effective implementation requires the buy-in of all members of the OR team. This depends on leadership, and on an understanding of the Checklists wider objectives.21 Improvement requires concerted effort over time. In a large Veterans Health Administration (VHA) controlled study, training of medical teams in briefings, debriefings and the Checklist (amongst other things) was associated with a steady decrease in mortality over the duration of the study (to an overall reduction in annual mortality of 18% compared with 7% in the control group).22 There needs to be a sustained shift in teamwork, communication and attitude to safety, which does not happen instantly (see Box 1).Box 1: An implementation case study: Ontario The Canadian government mandated compliance with use of the Surgical Safety Checklist as a compulsory patient safety indicator to be reported on biannually by Ontario hospitals in 2010.23 A March 2014 study of 101 Ontario hospitals failed to show statistically significant improvement in mortality or complications three months after the Checklists introduction.24 Adjusted risk of death was 0.71% (95% confidence interval: 0.66 to 0.76) before and 0.65% (0.60 to 0.70) after implementation of the Checklist (p=0.07). On the day of the studys publication, Canadas largest circulated national newspaper wrote, a large new Canadian study is calling the checklist orthodoxy into question. 25 However, many of the procedures were elective, with low baseline mortality, and the study may have been underpowered. More importantly, three months is simply too early to expect any substantial shift in practice, particularly in the absence of a thorough implementation initiative. In response to the Ontario findings, Haynes et al noted, Government-mandated adoption often results in high rates of reported compliance without true behavior change. 26 Two recent papers from the UK and Spain also support a similar discrepancy between reported compliance and meaningful compliance that is, between ticking boxes and using the Checklist effectively arising from centrally mandated use without work to promote the buy-in of clinicians.27,28 The authors of the Ontario study acknowledged the challenges associated with mandated use.24 In an accompanying editorial, Lucien Leape suggested, The likely reason for the failure of the surgical checklist [was] that it was not actually used. 29 The study did not measure compliance, which is akin to a drug trial with no measure of how many participants actually took the drug. The findings of this study add an important contribution to our understanding of the role of the Checklist. It is, and always has been, just a new tool to facilitate process improvement. Tools only work if used and, indeed, used well. A New Zealand perspectiveThe WHO Surgical Safety Checklist is used in the majority of surgical cases in New Zealand, in every government hospital and in the vast majority of private facilities. However, although adoption of the Checklist is widespread, a recent survey has shown that use is not consistent, and that there is considerable variability in participation across professional groups.30 This is likely to undermine the Checklists potential benefits and there is ongoing effort to evaluate barriers to compliance with administration of the Checklist and to engagement of OR teams in the process, and to identify ways in these barriers can be broken down.Since participation in the original WHO Checklist study,11 the University of Auckland Group has maintained a long-term focus on studying these matters. Utilising direct observations by trained collaborators, they have demonstrated variable compliance with administration of the three Checklist domains (Sign In, Time Out, Sign Out) and the associated Checklist items in a milieu where all Checklist domains are initiated and led by the circulating nurse from a paper copy of the Checklist. For example, an audit published in 201131 quantified compliance in the Auckland District Health Board (DHB) OR suite that participated in the original WHO study. Several years after completion of the study, there was good compliance with administration of the Sign In and Time Out domains (99% and 94% respectively), but the Sign Out domain was administered on only 2% of occasions. There was substantial variation in compliance with administration of the individual Checklist items, with some being articulated in 100% of cases, while others were used on as few as 27% of occasions. A second audit in the same operating suite some two years later reported little change in these compliance data, although the Sign Out domain had improved to 22% of occasions.32Another concerning outcome of both studies was the finding that engagement of the OR teams (surgeons, nurses, and anaesthetists) in the process was poor, even when a liberal definition of team engagement was used; at least one member of the team must have ceased all activity apart from attending to the Checklist for the team to be considered engaged. For example, during Time Out when all three teams were invariably present, engagement of all teams was only seen on 14% of occasions.32 Similarly, during Sign In, when the nursing and anaesthesia teams were invariably present (and surgeons almost always absent), engagement of both teams present was only seen on 39% of occasions. It was also telling that in 300 Checklist domains observed there was not one instance where all staff (every member of every team) in the OR were properly engaged in Checklist administration.Considerable thought has been given to identifying the reasons for the various problems identified in the above studies.Omission of Sign Out appeared attributable to the fact that it was not as clearly linked to an identifiable OR event as the other two Checklist domains. There was thus no naturally occurring aide-m\u00e9moire to signal that Sign Out should be initiated.31Selectivity in Checklist item administration appeared attributable to value judgments by administering staff as to which items were most important, or to perceptions that some questions might elicit a petulant response. For example, during Sign In, Checklist items with obvious face validity (those related to patient identity and the nature of the surgical procedure) were administered in 100% of cases. In contrast, checks on whether an airway problem was anticipated, or whether the surgeon was available, were administered in approximately 25% of cases.31 One item (the question about the anaesthetic machine check) typically elicited an irritable response and was the least-often administered (20% of cases). The latter illustrates the potential for negativity where the Checklist queries practices that a team might consider are culturally engrained or immutably embedded in their practice.Poor team engagement appeared primarily attributable to distractions by other concurrent tasks. For example, anaesthetists were prone to continuing with tasks like intravenous line insertion while the nurse administered Sign In, and surgeons were prone to continue to arrange the operating field while the nurse administered Time Out. Such disengagement by senior clinicians proved demotivating to the nurses, and there was a tendency for the Checklist administration to be truncated, but for tick-boxes to be checked anyway to indicate compliance.33 This practice has been noted in other New Zealand surveys.34Strategies to address all of these issues have been conceived and are in the process of being rolled out across Auckland DHB. A policy to link Sign Out to completion of the first swab and instrument count has brought clarity and consistency to the timing of this domain. After consultation with staff, all domains of the Checklist have been modified in order to remove some redundant items and to clarify the meaning of others. Most significantly, a radical change in the administration paradigm has been introduced. Paper Checklists and their associated tick boxes have been abandoned, and the Checklist now appears in all ORs as three large wall charts (one for each domain) that can be read from a distance. The anaesthetist leads the Sign In domain, and the surgeon leads the Time Out domain; the obvious logic being that placing the team most prone to disengagement in charge of administering the relevant domain is likely to ensure they remain engaged. The use of this system in the Counties Manukau DHB ORs appeared to result in better team engagement.32Airline pilots do not tick boxes on forms when they use a checklist. The Checklist was never intended to be used to record compliance with key processes it was intended to improve compliance with these processes. Changing to a shared leadership paradigm and abandoning the ticking of boxes should make that explicit. The impact of these changes on compliance and engagement in the first Auckland DHB OR suite to roll them out is being audited, and it is hoped that the Auckland DHB experience may inform decisions regarding Checklist practice being considered by other DHBs across the country. These changes have been applauded and endorsed by the Commission, which has taken steps to ensure that they are reflected positively in the relevant national Quality and Safety Marker.35Briefings and debriefings for surgical teamsIn the 1970s, investigators discovered that human error accounted for 70% of all crashes in aviation, and that the majority of these consisted of failures in leadership, team coordination and decision-making. 36 Communication failures are also the primary source of human error in the OR: in the US, the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) reports communication as the root cause in more than 75% of operative and postoperative sentinel events.37,38 Team briefings and debriefings have been used routinely in air forces and the aviation industry for decades, and more recently as part of NASAs Crew Resource Management (CRM), to combat these difficulties in communication in the cockpit. The introduction of briefings and debriefings to the OR has been more recent, but their value is becoming increasingly clear.Einav and colleagues found surgical briefings reduced the number of nonroutine events per operation by 25% (from 2.1 to 1.6 events) and increased the number in which no nonroutine event was observed at all.39 Lingard et al reported a decrease in communication failures in the OR (late, inaccurate, unresolved, or exclusive communications) from 3.95 per procedure before introduction of briefings to 1.31 after.40A 2012 study in a large medical centre in Michigan found that briefings and debriefings were a practical and effective strategy to surface potential surgical defects. 41 Using the Safety Attitudes Questionnaire, Makary and colleagues found briefings accounted for a reduction in OR staffs perception of risk for wrong-site surgery, and improved perceived collaboration.42Teams also report improvements in efficiency with briefings and debriefings, in contrast to some perceptions to the contrary.43 For example, a Johns Hopkins study found preoperative briefings were associated with a 19% reduction in communication breakdowns in the OR, a 31% reduction in unexpected delays, and an 82% reduction in surgeon-reported unexpected delays.44In the UK, use of both checklist and briefing CRM techniques reduced list time to the point one orthopaedic surgeon commented he had increased his list from four to five hip replacements.45BriefingsBriefings are used to share important information between different team members and groups to orient them around the tasks ahead, and to anticipate potential unexpected events or deviations from normal practice. Einav and colleagues observe, Surgical teams\u2026are frequently not familiar with all of the available data and may be only partially informed about the surgical plan. 39 Briefings are a simple, short verbal interchange involving the whole operating team prior to commencement of a list, designed to ensure the team members have shared mental models and interpretations of plans, priorities, and potential hazards to patients. Their readiness and cohesion as a team is thereby increased.46Figure 3 below shows a recommended structure for briefings, which can be tailored to individual local practice and context.Figure 3: Structuring a briefing. DebriefingsDebriefings, used by flight crews since World War Two, are a form of post-action review. They are the systematic process of sharing observations and interpretations of team processes and performance after the operation be it military or surgical is complete.47 Debriefings enable teams to take the time to reflect and learn as a group from a real-time situation. After a list is complete, a team shares what went well and what didnt go to plan, what can be learnt and what can be improved, and provide a forum to say thank you or simply, well done.Figure 4 shows a recommended structure for debriefings, which can be tailored to individual local practice and context.Figure 4: Structuring a debriefing. Complexity, autonomy and teamworkBriefings and debriefings complement the use of the Checklist, and as explained above, several major studies have shown the benefit of more comprehensive initiatives that incorporate various aspects of improving teamwork, communication and the reliability of process into surgical practice. The value of this becomes clear if one reflects on some basic principles of human performance in complex systems. Human error is inevitable particularly under stressful conditions .48 The prime objective of most checklists is to mitigate this inevitability. However, at the heart of the WHO initiative is something much more fundamental than simply avoiding mistakes. 49 Checklists are a way of bridging the simple, the complicated and the complex, of promoting uniformity in key practices, and of welding a team together around the needs of the patient before them.In The Checklist Manifesto,50 Gawande draws from Zimmerman and Glouberman51 to describe and make clear this distinction between simple, complicated and complex situations using the example of an error during the excision of a rare kind of tumour (see Box 2).Box 2: Kinds of situations and perioperative examples (adapted from running text in Gawande A. The Checklist Manifesto) Example Perioperative examples Simple Baking a cake from a mix there is a recipe Anaesthetic machine check; ensuring there are sufficient units in the blood bank for a foreseeable complication Complicated Sending someone to the moon iterable, steps can be established, a series of problems surmounted, but no straightforward recipe exists Removal of an adrenal gland containing a pheochromocytoma Complex Organic, and not iterable, like raising a child. Expertise is valuable, but most certainly not sufficient...[and] outcomes remain highly uncertain. 50 Ensuring the team is sufficiently in sync to respond rapidly and adequately to an accidentally torn vena cava Healthcare is, overall, a complex system. A surgical operation in itself should be a complicated process rather than a complex one. In some cases it should be a simple process and certainly there are common aspects of all surgical operations that are just a matter of process that is simple but essential. A prime objective of the Checklist is to get these simple and complicated processes right, every time.In the example from Gawande, during Sign In the Checklist item prompted him to mention the potential for large blood loss; this reminded the nurse to check with the blood bank; there she found that units of packed red blood cells were missing, and this problem was addressed before it occurred. This is an example of getting a simple process right.The Checklist aims to do more than this. In fact, it isnt strictly just a checklist, and it is certainly not designed to dumb down surgery or anaesthesia. Instead, it is a tool that asks clinicians to think, collaborate and plan around their patients, that also includes some important items to check. The expertise of our teams is not in doubt, but there are ever-present challenges to good teamwork in the OR: traditional training; fear of speaking out; power gradients; silo thinking; unstable teams; and shifting leadership. Good teamwork and communication become increasingly important as situations move from the routine and simple or complicated into the unexpected and complex. It is when decisions have to be made quickly without the benefit of regular practice that lives can be saved or lost by the way in which the team works as a team. In Gawandes example, he believes that when the emergency occurred, not just the retrieved units, but also the teamwork and intimacy generated by the process of using the Checklist contributed to effective and coordinated efforts that were successful in saving a life as the patient lost almost his entire volume of blood into his abdomen within 60 seconds.50Willingness is all. In New Zealand, where informality is key, we have a unique opportunity to build on that informality and more rapidly tap the Checklists power to help us better communicate as a team around anaesthetised patients needs, rather than around spurious or outdated hierarchies and perceived rights to practise autonomously. Autonomy, based on authority, is outmoded healthcare today. It is reasonable for patients to expect that teams will work together to implement evidence-based medicine, and that appropriate tools will be used to improve the reliability of processes. When asked, patients support the use of the Checklist.34 Good teamwork and communication avoids harm, saves lives, and improves efficiency,52-54 and so do simple tools to improve processes through checking.Venous thromboembolism (VTE), surgical safety and the ChecklistThe WHO Surgical Safety Checklist was always intended to be modifiable and tailored to the processes, methods and contexts of the countries and facilities where it is used. Ensuring that adequate VTE prophylaxis has taken place before skin incision is a core part of the Checklist as adapted for the New Zealand context, as it is for the NHS Checklist in England and Wales, and elsewhere.55,56 The implications of VTE prophylaxis are different in different areas Asia, for example, where reported rates are very low.57Despite the evidence, and the availability of clinical practice guidelines for the last twenty years, and the clear arguments for risk assessment screening and prophylaxis, effective VTE prophylaxis remains underused or variably used in New Zealand operating theatres.The Health Quality & Safety Commissions June 2014 Perioperative Mortality Review Committee report showed a PE-associated mortality rate in New Zealand of 8.7 per 100,000 patients who underwent an elective or waiting list procedure.58 About one in ten patients experiencing a PE will die as a result of their PE.59,60 Thats about one death from PE in every 11,500 procedures in this country.The risk of VTE increases tenfold in patients admitted to hospital, with contributing factors including general ill health or comorbidities, reduced mobility, smoking, and poor fluid intake. Major surgical procedures (particularly orthopaedic and other high-risk operations) are further risk factors, but patients who had short or minor procedures have also developed fatal PE. The incidence of PE is related to age Australian data show peak incidence of DVT and PE in the 75\u201379 year old age group but those aged 55\u201359 still contributed more than half the numbers of the older group. New Zealand estimates are lacking, but total hospital inpatient expenditure on VTE in Australia in 2008 was estimated at AUD 81.2 million, with each case of VTE costing in excess of $10,000.61Recurrence of proximal DVT occurs in up to 30% of patients within ten years of a first episode of venography-confirmed DVT, as does postphlebitic syndrome.62 DVT alone is still an issue, as it can lead to complication after complication.63Often surgeons can falsely assume anaesthetists have overseen DVT prophylaxis, and conversely.64Prevention and screening are crucial treatment of PE is difficult, and with fatal PE, 70% of patients die within three hours of onset of symptoms.63 Appropriate options for thromprophylaxis include pharmacological methods, such as the use of anticoagulants, and mechanical measures, such as compression stockings or intermittent pneumatic compression devices (IPC). Patients are an important part of their own care, and it is important to keep them informed of more general measures such as drinking enough water, keeping active, and wearing compression stockings postoperatively. A combination of these thromboprophylactic techniques has been shown to reduce the risk of DVT and both fatal and non-fatal PE by more than 60%.65 The choice of thromboprophylaxis is less important than the need to consider it in every patient and implement some reasonable strategy in those who are at risk. Therefore, the New Zealand Checklist simply asks, Has the plan for VTE prophylaxis during the operation been carried out? As clinicians, it is worth reflecting on the fact that this question might matter to us if and when we become patients.ConclusionEffective teamwork, communication, and a high degree of reliability in process (including, notably, VTE prophylaxis) in surgical practice are crucial to reduce instances of perioperative harm. There is strong evidence that engaged and effective use of the WHO Surgical Safety Checklist can reduce patient harm, and briefings and debriefings can add to these gains while simultaneously improving efficiency. The Health Quality & Safety Commissions Safe Surgery NZ programme is designed to ensure that the excellent outcomes sought for surgical patients in New Zealand are actually achieved. The Commission is grateful for the work undertaken by clinicians and DHBs to date.

Summary

Abstract

New Zealand appears to have a relatively high rate of perioperative adverse events. The Health Quality & Safety Commissions Safe Surgery NZ programme was introduced to address the rates of perioperative harm in New Zealand by promoting proper and effective use of the World Health Organization (WHO) Surgical Safety Checklist, and by encouraging use of operating room (OR) team briefings and debriefings. Venous thromboembolism prophylaxis is a key part of the checklist as deployed in New Zealand ORs, but it remains underused or variably used as well. Communication and teamwork are critical to improving patient safety and efficiency in the OR, and these interventions have demonstrated effectiveness in building and melding effective teams.

Aim

Method

Results

Conclusion

Author Information

Will Perry, General surgery trainee, Royal Australasian College of Surgeons, and member, Health Quality & Safety Commission Safe Surgery NZ Advisory Board; Ian Civil, Surgeon, Auckland City Hospital, and clinical lead, Health Quality & Safety Commission Safe Surgery NZ Programme; Simon Mitchell, Head of Department of Anaesthesiology, University of Auckland, and consultant anaesthetist, Auckland City Hospital; Carl Shuker, Principal advisor, publications, Health Quality & Safety Commission, Wellington; Alan Merry, Chair of the Board of the Health Quality & Safety Commission; and head of the School of Medicine at the University of Auckland.

Acknowledgements

Correspondence

Alan F Merry, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland.

Correspondence Email

a.merry@auckland.ac.nz

Competing Interests

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Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. Paediatr Anaesth. 2007 May;17(5):470-8. Mazzocco K, Petitti DB, Fong KT, et al. Surgical team behaviors and patient outcomes. Am J Surg. 2009 May;197(5):678-85. Health Quality & Safety Commission. Surgical Safety Checklist (Australia & New Zealand). http://www.hqsc.govt.nz/our-programmes/reducing-perioperative-harm/publications-and-resources/publication/587/. Adapted from the World Health Organization Surgical Safety Checklist by the Royal Australasian College of Surgeons in consultation with the Australian and New Zealand College of Anaesthetists, the Royal Australian and New Zealand College of Ophthalmologists, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, the Australian College of Operating Room Nurses and the Perioperative Nurses College of the New Zealand Nurses Organisation. Fujita Y, Nakatsuka H, Namba Y, Mitani S, Yoshitake N, Sugimoto E, et al. The incidence of pulmonary embolism and deep vein thrombosis and their predictive risk factors after lower extremity arthroplasty: a retrospective analysis based on diagnosis using multidetector CT. J Anesth. 2014 Aug 6. [Epub ahead of print] Health Quality & Safety Commission; Perioperative Mortality Review Committee. Third report of the Perioperative Mortality Review Committee. June 2014. http://www.hqsc.govt.nz/our-programmes/mrc/pomrc/publications-and-resources/publication/1575/. MacDougall DA, Feliu AL, Boccuzzi SJ, Lin J. Economic burden of deep-vein thrombosis, pulmonary embolism, and post-thrombotic syndrome. Am J Health Syst Pharm. 2006;63(20 Suppl 6):S5-15. Matsumoto AH, Tegtmeyer CJ. Contemporary diagnostic approaches to acute pulmonary emboli. Radiol Clin North Am. 1995;33(1):167-83. Access Economics. The burden of venous thromboembolism in Australia. May 2008. Prandoni P, Villalta S, Bagatella P, et al. The clinical course of deep-vein thrombosis. Prospective long-term follow-up of 528 symptomatic patients. Haematologica. 1997 Jul-Aug;82(4):423-8. Gallus A. Medicine Grand Round Professor Alexander Gallus. Ko Awatea. http://vimeo.com/65690462. Worrall M. Chocks away? Time for a surgical checklist. Bull R Coll Surg, 2008;90(9):304-5. Geerts W. Prevention of venous thromboembolism: a key patient safety priority. J Thromb Haemost. 2009;7(1):1-8.-

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Perioperative harm in New ZealandSince inception, the New Zealand Health Quality & Safety Commission (the Commission) has been particularly interested in the reduction of perioperative harm in our operating rooms (ORs). New Zealand appears to have a relatively high rate of perioperative adverse events. OECD data from 2012/13 suggested New Zealand had one of the highest documented rates of postoperative sepsis (1,260 per 100,000 hospital discharges in 2012/2013), the third highest rate of foreign bodies left in during a procedure (10.8 per 100,000 discharges), and was six countries behind the average for pulmonary embolism and deep vein thrombosis (PE and DVT), with a crude rate of 912 per 100,000 discharges. Only four OECD countries reported worse rates.1Some argue that we are simply better at recording adverse outcomes, but regardless, these numbers are unacceptable. The Commissions Safe Surgery NZ programme was set up specifically to improve this situation through promulgation of several evidence-based interventions, including the World Health Organization (WHO) Surgical Safety Checklist, surgical team briefings and debriefings, and effective venous thromboembolism prophylaxis. These formed the backbone of the recent focus on reducing perioperative harmin the Open for Better Care campaign. This article provides background and context to this work, and a discussion of the evolution of perioperative care in New Zealand.WHO Surgical Safety ChecklistFigure 1:World Alliance for Patient Safetys Ten Objectives for Safe SurgeryThe WHO Surgical Safety Checklist (the Checklist) is an evidence-based 19-item tool designed to improve patient outcomes by reducing error and improving teamwork and communication in the OR. The World Alliance for Patient Safety, recognising the unacceptably high rate of perioperative morbidity and mortality, identified ten universal objectives for safe surgery (see Figure 1) through consultative work in its second global challenge, the Safe Surgery Saves Lives initiative.2 These objectives were underpinned by an appreciation of the importance of teamwork in achieving good outcomes for patients undergoing surgery.The success of checklists in high-reliability organisations such as aviation, the military, and nuclear power, as well as in central line infections,3,4 inspired the development of this tool (see Figure 2) to help achieve these objectives. From the outset, the Checklist was designed to improve teamwork, communication and culture in addition to facilitating certain important checks,5,6 and there is increasing evidence that its effective use can achieve all of these things.7-10Figure 2: Surgical Safety Checklist (Australia and New Zealand) The University of Auckland and Auckland City Hospital collaborated as one of the eight international sites in the initial evaluation of the Checklist; introducing the Checklist was associated with substantial reductions in perioperative mortality (from 1.5% to 0.8%), and complications (from 11% to 7%).11Numerous studies have supplemented these initial findings,6,10,12-14 and results have been integrated into two systematic reviews.15,16 Some extended the scope of the intervention, but collectively they provide considerable support for training, briefings (see below), and other initiatives aligned with the Checklist in promoting teamwork, communication, and safety. The Netherlands Surgical Patient Safety System (SURPASS), for example, found a significant reduction in in-hospital mortality (1.5% to 0.8%) and in overall complications (27.3 to 16.7 per 100) after implementation of a comprehensive surgical checklist.17 More recently, a stepped-wedge cluster randomised controlled trial showed a reduction in complications from 19.9% to 11.5% with the use of the Checklist, giving an absolute risk reduction of 8.4. Length of stay decreased by 0.8 days, and mortality was significantly decreased in one of the two study centres, but not the other.18 Semel et al found its use reduced cost as well as harm,19 and a New Zealand analysis has suggested it will provide an annual steady state benefit of NZD 5.7 million to our health system, primarily through avoided complications of surgical care.20The introduction of the Checklist has not come without its challenges. Effective implementation requires the buy-in of all members of the OR team. This depends on leadership, and on an understanding of the Checklists wider objectives.21 Improvement requires concerted effort over time. In a large Veterans Health Administration (VHA) controlled study, training of medical teams in briefings, debriefings and the Checklist (amongst other things) was associated with a steady decrease in mortality over the duration of the study (to an overall reduction in annual mortality of 18% compared with 7% in the control group).22 There needs to be a sustained shift in teamwork, communication and attitude to safety, which does not happen instantly (see Box 1).Box 1: An implementation case study: Ontario The Canadian government mandated compliance with use of the Surgical Safety Checklist as a compulsory patient safety indicator to be reported on biannually by Ontario hospitals in 2010.23 A March 2014 study of 101 Ontario hospitals failed to show statistically significant improvement in mortality or complications three months after the Checklists introduction.24 Adjusted risk of death was 0.71% (95% confidence interval: 0.66 to 0.76) before and 0.65% (0.60 to 0.70) after implementation of the Checklist (p=0.07). On the day of the studys publication, Canadas largest circulated national newspaper wrote, a large new Canadian study is calling the checklist orthodoxy into question. 25 However, many of the procedures were elective, with low baseline mortality, and the study may have been underpowered. More importantly, three months is simply too early to expect any substantial shift in practice, particularly in the absence of a thorough implementation initiative. In response to the Ontario findings, Haynes et al noted, Government-mandated adoption often results in high rates of reported compliance without true behavior change. 26 Two recent papers from the UK and Spain also support a similar discrepancy between reported compliance and meaningful compliance that is, between ticking boxes and using the Checklist effectively arising from centrally mandated use without work to promote the buy-in of clinicians.27,28 The authors of the Ontario study acknowledged the challenges associated with mandated use.24 In an accompanying editorial, Lucien Leape suggested, The likely reason for the failure of the surgical checklist [was] that it was not actually used. 29 The study did not measure compliance, which is akin to a drug trial with no measure of how many participants actually took the drug. The findings of this study add an important contribution to our understanding of the role of the Checklist. It is, and always has been, just a new tool to facilitate process improvement. Tools only work if used and, indeed, used well. A New Zealand perspectiveThe WHO Surgical Safety Checklist is used in the majority of surgical cases in New Zealand, in every government hospital and in the vast majority of private facilities. However, although adoption of the Checklist is widespread, a recent survey has shown that use is not consistent, and that there is considerable variability in participation across professional groups.30 This is likely to undermine the Checklists potential benefits and there is ongoing effort to evaluate barriers to compliance with administration of the Checklist and to engagement of OR teams in the process, and to identify ways in these barriers can be broken down.Since participation in the original WHO Checklist study,11 the University of Auckland Group has maintained a long-term focus on studying these matters. Utilising direct observations by trained collaborators, they have demonstrated variable compliance with administration of the three Checklist domains (Sign In, Time Out, Sign Out) and the associated Checklist items in a milieu where all Checklist domains are initiated and led by the circulating nurse from a paper copy of the Checklist. For example, an audit published in 201131 quantified compliance in the Auckland District Health Board (DHB) OR suite that participated in the original WHO study. Several years after completion of the study, there was good compliance with administration of the Sign In and Time Out domains (99% and 94% respectively), but the Sign Out domain was administered on only 2% of occasions. There was substantial variation in compliance with administration of the individual Checklist items, with some being articulated in 100% of cases, while others were used on as few as 27% of occasions. A second audit in the same operating suite some two years later reported little change in these compliance data, although the Sign Out domain had improved to 22% of occasions.32Another concerning outcome of both studies was the finding that engagement of the OR teams (surgeons, nurses, and anaesthetists) in the process was poor, even when a liberal definition of team engagement was used; at least one member of the team must have ceased all activity apart from attending to the Checklist for the team to be considered engaged. For example, during Time Out when all three teams were invariably present, engagement of all teams was only seen on 14% of occasions.32 Similarly, during Sign In, when the nursing and anaesthesia teams were invariably present (and surgeons almost always absent), engagement of both teams present was only seen on 39% of occasions. It was also telling that in 300 Checklist domains observed there was not one instance where all staff (every member of every team) in the OR were properly engaged in Checklist administration.Considerable thought has been given to identifying the reasons for the various problems identified in the above studies.Omission of Sign Out appeared attributable to the fact that it was not as clearly linked to an identifiable OR event as the other two Checklist domains. There was thus no naturally occurring aide-m\u00e9moire to signal that Sign Out should be initiated.31Selectivity in Checklist item administration appeared attributable to value judgments by administering staff as to which items were most important, or to perceptions that some questions might elicit a petulant response. For example, during Sign In, Checklist items with obvious face validity (those related to patient identity and the nature of the surgical procedure) were administered in 100% of cases. In contrast, checks on whether an airway problem was anticipated, or whether the surgeon was available, were administered in approximately 25% of cases.31 One item (the question about the anaesthetic machine check) typically elicited an irritable response and was the least-often administered (20% of cases). The latter illustrates the potential for negativity where the Checklist queries practices that a team might consider are culturally engrained or immutably embedded in their practice.Poor team engagement appeared primarily attributable to distractions by other concurrent tasks. For example, anaesthetists were prone to continuing with tasks like intravenous line insertion while the nurse administered Sign In, and surgeons were prone to continue to arrange the operating field while the nurse administered Time Out. Such disengagement by senior clinicians proved demotivating to the nurses, and there was a tendency for the Checklist administration to be truncated, but for tick-boxes to be checked anyway to indicate compliance.33 This practice has been noted in other New Zealand surveys.34Strategies to address all of these issues have been conceived and are in the process of being rolled out across Auckland DHB. A policy to link Sign Out to completion of the first swab and instrument count has brought clarity and consistency to the timing of this domain. After consultation with staff, all domains of the Checklist have been modified in order to remove some redundant items and to clarify the meaning of others. Most significantly, a radical change in the administration paradigm has been introduced. Paper Checklists and their associated tick boxes have been abandoned, and the Checklist now appears in all ORs as three large wall charts (one for each domain) that can be read from a distance. The anaesthetist leads the Sign In domain, and the surgeon leads the Time Out domain; the obvious logic being that placing the team most prone to disengagement in charge of administering the relevant domain is likely to ensure they remain engaged. The use of this system in the Counties Manukau DHB ORs appeared to result in better team engagement.32Airline pilots do not tick boxes on forms when they use a checklist. The Checklist was never intended to be used to record compliance with key processes it was intended to improve compliance with these processes. Changing to a shared leadership paradigm and abandoning the ticking of boxes should make that explicit. The impact of these changes on compliance and engagement in the first Auckland DHB OR suite to roll them out is being audited, and it is hoped that the Auckland DHB experience may inform decisions regarding Checklist practice being considered by other DHBs across the country. These changes have been applauded and endorsed by the Commission, which has taken steps to ensure that they are reflected positively in the relevant national Quality and Safety Marker.35Briefings and debriefings for surgical teamsIn the 1970s, investigators discovered that human error accounted for 70% of all crashes in aviation, and that the majority of these consisted of failures in leadership, team coordination and decision-making. 36 Communication failures are also the primary source of human error in the OR: in the US, the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) reports communication as the root cause in more than 75% of operative and postoperative sentinel events.37,38 Team briefings and debriefings have been used routinely in air forces and the aviation industry for decades, and more recently as part of NASAs Crew Resource Management (CRM), to combat these difficulties in communication in the cockpit. The introduction of briefings and debriefings to the OR has been more recent, but their value is becoming increasingly clear.Einav and colleagues found surgical briefings reduced the number of nonroutine events per operation by 25% (from 2.1 to 1.6 events) and increased the number in which no nonroutine event was observed at all.39 Lingard et al reported a decrease in communication failures in the OR (late, inaccurate, unresolved, or exclusive communications) from 3.95 per procedure before introduction of briefings to 1.31 after.40A 2012 study in a large medical centre in Michigan found that briefings and debriefings were a practical and effective strategy to surface potential surgical defects. 41 Using the Safety Attitudes Questionnaire, Makary and colleagues found briefings accounted for a reduction in OR staffs perception of risk for wrong-site surgery, and improved perceived collaboration.42Teams also report improvements in efficiency with briefings and debriefings, in contrast to some perceptions to the contrary.43 For example, a Johns Hopkins study found preoperative briefings were associated with a 19% reduction in communication breakdowns in the OR, a 31% reduction in unexpected delays, and an 82% reduction in surgeon-reported unexpected delays.44In the UK, use of both checklist and briefing CRM techniques reduced list time to the point one orthopaedic surgeon commented he had increased his list from four to five hip replacements.45BriefingsBriefings are used to share important information between different team members and groups to orient them around the tasks ahead, and to anticipate potential unexpected events or deviations from normal practice. Einav and colleagues observe, Surgical teams\u2026are frequently not familiar with all of the available data and may be only partially informed about the surgical plan. 39 Briefings are a simple, short verbal interchange involving the whole operating team prior to commencement of a list, designed to ensure the team members have shared mental models and interpretations of plans, priorities, and potential hazards to patients. Their readiness and cohesion as a team is thereby increased.46Figure 3 below shows a recommended structure for briefings, which can be tailored to individual local practice and context.Figure 3: Structuring a briefing. DebriefingsDebriefings, used by flight crews since World War Two, are a form of post-action review. They are the systematic process of sharing observations and interpretations of team processes and performance after the operation be it military or surgical is complete.47 Debriefings enable teams to take the time to reflect and learn as a group from a real-time situation. After a list is complete, a team shares what went well and what didnt go to plan, what can be learnt and what can be improved, and provide a forum to say thank you or simply, well done.Figure 4 shows a recommended structure for debriefings, which can be tailored to individual local practice and context.Figure 4: Structuring a debriefing. Complexity, autonomy and teamworkBriefings and debriefings complement the use of the Checklist, and as explained above, several major studies have shown the benefit of more comprehensive initiatives that incorporate various aspects of improving teamwork, communication and the reliability of process into surgical practice. The value of this becomes clear if one reflects on some basic principles of human performance in complex systems. Human error is inevitable particularly under stressful conditions .48 The prime objective of most checklists is to mitigate this inevitability. However, at the heart of the WHO initiative is something much more fundamental than simply avoiding mistakes. 49 Checklists are a way of bridging the simple, the complicated and the complex, of promoting uniformity in key practices, and of welding a team together around the needs of the patient before them.In The Checklist Manifesto,50 Gawande draws from Zimmerman and Glouberman51 to describe and make clear this distinction between simple, complicated and complex situations using the example of an error during the excision of a rare kind of tumour (see Box 2).Box 2: Kinds of situations and perioperative examples (adapted from running text in Gawande A. The Checklist Manifesto) Example Perioperative examples Simple Baking a cake from a mix there is a recipe Anaesthetic machine check; ensuring there are sufficient units in the blood bank for a foreseeable complication Complicated Sending someone to the moon iterable, steps can be established, a series of problems surmounted, but no straightforward recipe exists Removal of an adrenal gland containing a pheochromocytoma Complex Organic, and not iterable, like raising a child. Expertise is valuable, but most certainly not sufficient...[and] outcomes remain highly uncertain. 50 Ensuring the team is sufficiently in sync to respond rapidly and adequately to an accidentally torn vena cava Healthcare is, overall, a complex system. A surgical operation in itself should be a complicated process rather than a complex one. In some cases it should be a simple process and certainly there are common aspects of all surgical operations that are just a matter of process that is simple but essential. A prime objective of the Checklist is to get these simple and complicated processes right, every time.In the example from Gawande, during Sign In the Checklist item prompted him to mention the potential for large blood loss; this reminded the nurse to check with the blood bank; there she found that units of packed red blood cells were missing, and this problem was addressed before it occurred. This is an example of getting a simple process right.The Checklist aims to do more than this. In fact, it isnt strictly just a checklist, and it is certainly not designed to dumb down surgery or anaesthesia. Instead, it is a tool that asks clinicians to think, collaborate and plan around their patients, that also includes some important items to check. The expertise of our teams is not in doubt, but there are ever-present challenges to good teamwork in the OR: traditional training; fear of speaking out; power gradients; silo thinking; unstable teams; and shifting leadership. Good teamwork and communication become increasingly important as situations move from the routine and simple or complicated into the unexpected and complex. It is when decisions have to be made quickly without the benefit of regular practice that lives can be saved or lost by the way in which the team works as a team. In Gawandes example, he believes that when the emergency occurred, not just the retrieved units, but also the teamwork and intimacy generated by the process of using the Checklist contributed to effective and coordinated efforts that were successful in saving a life as the patient lost almost his entire volume of blood into his abdomen within 60 seconds.50Willingness is all. In New Zealand, where informality is key, we have a unique opportunity to build on that informality and more rapidly tap the Checklists power to help us better communicate as a team around anaesthetised patients needs, rather than around spurious or outdated hierarchies and perceived rights to practise autonomously. Autonomy, based on authority, is outmoded healthcare today. It is reasonable for patients to expect that teams will work together to implement evidence-based medicine, and that appropriate tools will be used to improve the reliability of processes. When asked, patients support the use of the Checklist.34 Good teamwork and communication avoids harm, saves lives, and improves efficiency,52-54 and so do simple tools to improve processes through checking.Venous thromboembolism (VTE), surgical safety and the ChecklistThe WHO Surgical Safety Checklist was always intended to be modifiable and tailored to the processes, methods and contexts of the countries and facilities where it is used. Ensuring that adequate VTE prophylaxis has taken place before skin incision is a core part of the Checklist as adapted for the New Zealand context, as it is for the NHS Checklist in England and Wales, and elsewhere.55,56 The implications of VTE prophylaxis are different in different areas Asia, for example, where reported rates are very low.57Despite the evidence, and the availability of clinical practice guidelines for the last twenty years, and the clear arguments for risk assessment screening and prophylaxis, effective VTE prophylaxis remains underused or variably used in New Zealand operating theatres.The Health Quality & Safety Commissions June 2014 Perioperative Mortality Review Committee report showed a PE-associated mortality rate in New Zealand of 8.7 per 100,000 patients who underwent an elective or waiting list procedure.58 About one in ten patients experiencing a PE will die as a result of their PE.59,60 Thats about one death from PE in every 11,500 procedures in this country.The risk of VTE increases tenfold in patients admitted to hospital, with contributing factors including general ill health or comorbidities, reduced mobility, smoking, and poor fluid intake. Major surgical procedures (particularly orthopaedic and other high-risk operations) are further risk factors, but patients who had short or minor procedures have also developed fatal PE. The incidence of PE is related to age Australian data show peak incidence of DVT and PE in the 75\u201379 year old age group but those aged 55\u201359 still contributed more than half the numbers of the older group. New Zealand estimates are lacking, but total hospital inpatient expenditure on VTE in Australia in 2008 was estimated at AUD 81.2 million, with each case of VTE costing in excess of $10,000.61Recurrence of proximal DVT occurs in up to 30% of patients within ten years of a first episode of venography-confirmed DVT, as does postphlebitic syndrome.62 DVT alone is still an issue, as it can lead to complication after complication.63Often surgeons can falsely assume anaesthetists have overseen DVT prophylaxis, and conversely.64Prevention and screening are crucial treatment of PE is difficult, and with fatal PE, 70% of patients die within three hours of onset of symptoms.63 Appropriate options for thromprophylaxis include pharmacological methods, such as the use of anticoagulants, and mechanical measures, such as compression stockings or intermittent pneumatic compression devices (IPC). Patients are an important part of their own care, and it is important to keep them informed of more general measures such as drinking enough water, keeping active, and wearing compression stockings postoperatively. A combination of these thromboprophylactic techniques has been shown to reduce the risk of DVT and both fatal and non-fatal PE by more than 60%.65 The choice of thromboprophylaxis is less important than the need to consider it in every patient and implement some reasonable strategy in those who are at risk. Therefore, the New Zealand Checklist simply asks, Has the plan for VTE prophylaxis during the operation been carried out? As clinicians, it is worth reflecting on the fact that this question might matter to us if and when we become patients.ConclusionEffective teamwork, communication, and a high degree of reliability in process (including, notably, VTE prophylaxis) in surgical practice are crucial to reduce instances of perioperative harm. There is strong evidence that engaged and effective use of the WHO Surgical Safety Checklist can reduce patient harm, and briefings and debriefings can add to these gains while simultaneously improving efficiency. The Health Quality & Safety Commissions Safe Surgery NZ programme is designed to ensure that the excellent outcomes sought for surgical patients in New Zealand are actually achieved. The Commission is grateful for the work undertaken by clinicians and DHBs to date.

Summary

Abstract

New Zealand appears to have a relatively high rate of perioperative adverse events. The Health Quality & Safety Commissions Safe Surgery NZ programme was introduced to address the rates of perioperative harm in New Zealand by promoting proper and effective use of the World Health Organization (WHO) Surgical Safety Checklist, and by encouraging use of operating room (OR) team briefings and debriefings. Venous thromboembolism prophylaxis is a key part of the checklist as deployed in New Zealand ORs, but it remains underused or variably used as well. Communication and teamwork are critical to improving patient safety and efficiency in the OR, and these interventions have demonstrated effectiveness in building and melding effective teams.

Aim

Method

Results

Conclusion

Author Information

Will Perry, General surgery trainee, Royal Australasian College of Surgeons, and member, Health Quality & Safety Commission Safe Surgery NZ Advisory Board; Ian Civil, Surgeon, Auckland City Hospital, and clinical lead, Health Quality & Safety Commission Safe Surgery NZ Programme; Simon Mitchell, Head of Department of Anaesthesiology, University of Auckland, and consultant anaesthetist, Auckland City Hospital; Carl Shuker, Principal advisor, publications, Health Quality & Safety Commission, Wellington; Alan Merry, Chair of the Board of the Health Quality & Safety Commission; and head of the School of Medicine at the University of Auckland.

Acknowledgements

Correspondence

Alan F Merry, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland.

Correspondence Email

a.merry@auckland.ac.nz

Competing Interests

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Effect of using a safety checklist on patient complications after surgery: a systematic review and meta-analysis. Anesthesiology. 2014 Jun;120(6):1380-9. Bergs J, Hellings J, Cleemput I, et al. Systematic review and meta-analysis of the effect of the World Health Organization surgical safety checklist on postoperative complications. Br J Surg. 2014 Feb;101(3):150-8. de Vries EN, Prins HA, Crolla RM, et al. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med. 2010 Nov 11;363(20):1928-37. Haugen AS, S\u00f8fteland E, Almeland SK, et al. Effect of the World Health Organization Checklist on Patient Outcomes: A Stepped Wedge Cluster Randomized Controlled Trial. Ann Surg. 2014 May 13. Semel ME, Resch S, Haynes AB, et al. Adopting a surgical safety checklist could save money and improve the quality of care in U.S. hospitals. Health Aff (Millwood). 2010 Sep;29(9):1593-9. Hefford M, Blick G. Cost benefit analysis of the surgical safety checklist: report prepared for Health Quality & Safety Commission. 18 June 2012. Perry WRG, Kelley ET. Checklists, global health and surgery: a five-year checkup of the WHO Surgical Safety checklist programme. Clinical Risk. May 2014;20(3):59-63. Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA 2010;304:1693-1700. Ontario Ministry of Health and Long-Term Care. Patient Safety Indicator results at Health Quality Ontario. http://www.health.gov.on.ca/en/public/programs/patient_safety/ Urbach DR, Govindarajan A, Saskin R, et al. Introduction of surgical safety checklists in Ontario, Canada. N Engl J Med. 2014 Mar 13;370(11):1029-38. Grant K. Surgical checklists have little effect on patient outcomes, study finds. 12 March 2014. http://www.theglobeandmail.com/news/national/surgical-checklists-have-little-effect-on-patient-outcomes-study-finds/article17473716/ Haynes AB, Berry WR, Gawande AA. Surgical safety checklists in Ontario, Canada. N Engl J Med. 2014 Jun 12;370(24):2350. Pickering SP, Robertson ER, Griffin D, et al. Compliance and use of the World Health Organization checklist in U.K. operating theatres. Br J Surg. 2013 Nov;100(12):1664-70. Saturno PJ, Soria-Aledo V, Da Silva Gama ZA, et al. Understanding WHO surgical checklist implementation: tricks and pitfalls. An observational study. World J Surg. 2014 Feb;38(2):287-95. Leape LL. The checklist conundrum. N Engl J Med. 2014 Mar 13;370(11):1063-4. Health Quality and Safety Commission. How well is your organisation using the WHO Surgical Safety Checklist? 4 August 2014. http://www.open.hqsc.govt.nz/assets/Open-for-better-care/Surgery/NEMR-files--images/checklist-survey-analysis-Aug-2014.pdf. Vogts N, Hannam JA, Merry AF, Mitchell SJ. Compliance and quality in administration of a Surgical Safety Checklist in a tertiary New Zealand hospital. N Z Med J. 2011 Sep 9;124(1342):48-58. Hannam JA, Glass L, Kwon J, et al. A prospective, observational study of the effects of implementation strategy on compliance with a surgical safety checklist. BMJ Qual Saf. 2013 Nov;22(11):940-7. Vogts N, Hannam JA, Mitchell SJ. Checking the checkers; self-reporting of the WHO Surgical Safety Checklist by OR staff. Auckland District Health Board Quality Account 2014-2015: In press 2015. Attitudes towards the Surgical Safety Checklist and its use in New Zealand operating theatres. Litmus. Prepared for the Health Quality and Safety Commission New Zealand. 19 October 2012. Hamblin R, Bohm G, Gerard C, et al. The measurement of New Zealand health care. N Z Med J. 2015. In press. American Psychological Association. Making Air Travel Safer Through Crew Resource Management. February 2014. Wolf FA, Way LW, Stewart L. The efficacy of medical team training: improved team performance and decreased operating room delays: a detailed analysis of 4863 cases. Ann Surg. 2010 Sep;252(3):477-83. Joint Commission. Joint Commission 2006 Sentinel Event Statistics 1995-2005. Einav Y, Gopher D, Kara I, et al. Preoperative briefing in the operating room: shared cognition, teamwork, and patient safety. Chest. 2010 Feb;137(2):443-9. Lingard L, Regehr G, Orser B, et al. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg. 2008 Jan;143(1):12-7; discussion 18. Bandari J, Schumacher K, Simon M, et al. Surfacing safety hazards using standardized operating room briefings and debriefings at a large regional medical center. Jt Comm J Qual Patient Saf. 2012 Apr;38(4):154-60. Makary MA, Mukherjee A, Sexton JB, et al. Operating room briefings and wrong-site surgery. J Am Coll Surg. 2007 Feb;204(2):236-43. Bethune R, Sasirekha G, Sahu A, et al. Use of briefings and debriefings as a tool in improving team work, efficiency, and communication in the operating theatre. Postgrad Med J. 2011 May;87(1027):331-4. Nundy S, Mukherjee A, Sexton JB, et al. Impact of preoperative briefings on operating room delays: a preliminary report. Arch Surg. 2008 Nov;143(11):1068-72. NHS Patient Safety First. The How to Guide for Reducing Harm in Perioperative Care. September 2009. http://www.patientsafetyfirst.nhs.uk/ashx/Asset.ashx?path=/How-to-guides-2008-09-19/periopcareLATEST%206%20Oct.pdf. Civil I, Shuker C. Briefings and debriefings in one surgeons practice. ANZ J Surg. 2015 May;85(5):321-3.. Vashdi DR, Bamberger PA, Erez M, Weiss-Meilik A. Briefing-debriefing: using a reflexive organizational learning model from the military to enhance the performance of surgical teams. Human Resource Management 2007:46(1):115-142. Hales BM, Pronovost PJ. The checklist--a tool for error management and performance improvement. J Crit Care. 2006;21:231\u20135. Merry AF, Mitchell SJ. The World Health Organization Safe Surgical Checklist: its time to engage. N Z Med J. 2012 Sep 21;125(1362):11-4. Gawande A. The Checklist Manifesto How to Get Things Right. Picador, 2011. Glouberman S, Zimmerman B, Complicated and Complex Systems: What Would Successful Reform of Medicare Look Like? Discussion paper #8, Commission on the Future of Health Care in Canada. 2002. Salas E, Sims DE, Burke CS. Is there a Big Five in teamwork? Small Group Research. 2005;36:555-99. Catchpole KR, de Leval MR, McEwan A, et al. Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. Paediatr Anaesth. 2007 May;17(5):470-8. Mazzocco K, Petitti DB, Fong KT, et al. Surgical team behaviors and patient outcomes. Am J Surg. 2009 May;197(5):678-85. Health Quality & Safety Commission. Surgical Safety Checklist (Australia & New Zealand). http://www.hqsc.govt.nz/our-programmes/reducing-perioperative-harm/publications-and-resources/publication/587/. Adapted from the World Health Organization Surgical Safety Checklist by the Royal Australasian College of Surgeons in consultation with the Australian and New Zealand College of Anaesthetists, the Royal Australian and New Zealand College of Ophthalmologists, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, the Australian College of Operating Room Nurses and the Perioperative Nurses College of the New Zealand Nurses Organisation. Fujita Y, Nakatsuka H, Namba Y, Mitani S, Yoshitake N, Sugimoto E, et al. The incidence of pulmonary embolism and deep vein thrombosis and their predictive risk factors after lower extremity arthroplasty: a retrospective analysis based on diagnosis using multidetector CT. J Anesth. 2014 Aug 6. [Epub ahead of print] Health Quality & Safety Commission; Perioperative Mortality Review Committee. Third report of the Perioperative Mortality Review Committee. June 2014. http://www.hqsc.govt.nz/our-programmes/mrc/pomrc/publications-and-resources/publication/1575/. MacDougall DA, Feliu AL, Boccuzzi SJ, Lin J. Economic burden of deep-vein thrombosis, pulmonary embolism, and post-thrombotic syndrome. Am J Health Syst Pharm. 2006;63(20 Suppl 6):S5-15. Matsumoto AH, Tegtmeyer CJ. Contemporary diagnostic approaches to acute pulmonary emboli. Radiol Clin North Am. 1995;33(1):167-83. Access Economics. The burden of venous thromboembolism in Australia. May 2008. Prandoni P, Villalta S, Bagatella P, et al. The clinical course of deep-vein thrombosis. Prospective long-term follow-up of 528 symptomatic patients. Haematologica. 1997 Jul-Aug;82(4):423-8. Gallus A. Medicine Grand Round Professor Alexander Gallus. Ko Awatea. http://vimeo.com/65690462. Worrall M. Chocks away? Time for a surgical checklist. Bull R Coll Surg, 2008;90(9):304-5. Geerts W. Prevention of venous thromboembolism: a key patient safety priority. J Thromb Haemost. 2009;7(1):1-8.-

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Perioperative harm in New ZealandSince inception, the New Zealand Health Quality & Safety Commission (the Commission) has been particularly interested in the reduction of perioperative harm in our operating rooms (ORs). New Zealand appears to have a relatively high rate of perioperative adverse events. OECD data from 2012/13 suggested New Zealand had one of the highest documented rates of postoperative sepsis (1,260 per 100,000 hospital discharges in 2012/2013), the third highest rate of foreign bodies left in during a procedure (10.8 per 100,000 discharges), and was six countries behind the average for pulmonary embolism and deep vein thrombosis (PE and DVT), with a crude rate of 912 per 100,000 discharges. Only four OECD countries reported worse rates.1Some argue that we are simply better at recording adverse outcomes, but regardless, these numbers are unacceptable. The Commissions Safe Surgery NZ programme was set up specifically to improve this situation through promulgation of several evidence-based interventions, including the World Health Organization (WHO) Surgical Safety Checklist, surgical team briefings and debriefings, and effective venous thromboembolism prophylaxis. These formed the backbone of the recent focus on reducing perioperative harmin the Open for Better Care campaign. This article provides background and context to this work, and a discussion of the evolution of perioperative care in New Zealand.WHO Surgical Safety ChecklistFigure 1:World Alliance for Patient Safetys Ten Objectives for Safe SurgeryThe WHO Surgical Safety Checklist (the Checklist) is an evidence-based 19-item tool designed to improve patient outcomes by reducing error and improving teamwork and communication in the OR. The World Alliance for Patient Safety, recognising the unacceptably high rate of perioperative morbidity and mortality, identified ten universal objectives for safe surgery (see Figure 1) through consultative work in its second global challenge, the Safe Surgery Saves Lives initiative.2 These objectives were underpinned by an appreciation of the importance of teamwork in achieving good outcomes for patients undergoing surgery.The success of checklists in high-reliability organisations such as aviation, the military, and nuclear power, as well as in central line infections,3,4 inspired the development of this tool (see Figure 2) to help achieve these objectives. From the outset, the Checklist was designed to improve teamwork, communication and culture in addition to facilitating certain important checks,5,6 and there is increasing evidence that its effective use can achieve all of these things.7-10Figure 2: Surgical Safety Checklist (Australia and New Zealand) The University of Auckland and Auckland City Hospital collaborated as one of the eight international sites in the initial evaluation of the Checklist; introducing the Checklist was associated with substantial reductions in perioperative mortality (from 1.5% to 0.8%), and complications (from 11% to 7%).11Numerous studies have supplemented these initial findings,6,10,12-14 and results have been integrated into two systematic reviews.15,16 Some extended the scope of the intervention, but collectively they provide considerable support for training, briefings (see below), and other initiatives aligned with the Checklist in promoting teamwork, communication, and safety. The Netherlands Surgical Patient Safety System (SURPASS), for example, found a significant reduction in in-hospital mortality (1.5% to 0.8%) and in overall complications (27.3 to 16.7 per 100) after implementation of a comprehensive surgical checklist.17 More recently, a stepped-wedge cluster randomised controlled trial showed a reduction in complications from 19.9% to 11.5% with the use of the Checklist, giving an absolute risk reduction of 8.4. Length of stay decreased by 0.8 days, and mortality was significantly decreased in one of the two study centres, but not the other.18 Semel et al found its use reduced cost as well as harm,19 and a New Zealand analysis has suggested it will provide an annual steady state benefit of NZD 5.7 million to our health system, primarily through avoided complications of surgical care.20The introduction of the Checklist has not come without its challenges. Effective implementation requires the buy-in of all members of the OR team. This depends on leadership, and on an understanding of the Checklists wider objectives.21 Improvement requires concerted effort over time. In a large Veterans Health Administration (VHA) controlled study, training of medical teams in briefings, debriefings and the Checklist (amongst other things) was associated with a steady decrease in mortality over the duration of the study (to an overall reduction in annual mortality of 18% compared with 7% in the control group).22 There needs to be a sustained shift in teamwork, communication and attitude to safety, which does not happen instantly (see Box 1).Box 1: An implementation case study: Ontario The Canadian government mandated compliance with use of the Surgical Safety Checklist as a compulsory patient safety indicator to be reported on biannually by Ontario hospitals in 2010.23 A March 2014 study of 101 Ontario hospitals failed to show statistically significant improvement in mortality or complications three months after the Checklists introduction.24 Adjusted risk of death was 0.71% (95% confidence interval: 0.66 to 0.76) before and 0.65% (0.60 to 0.70) after implementation of the Checklist (p=0.07). On the day of the studys publication, Canadas largest circulated national newspaper wrote, a large new Canadian study is calling the checklist orthodoxy into question. 25 However, many of the procedures were elective, with low baseline mortality, and the study may have been underpowered. More importantly, three months is simply too early to expect any substantial shift in practice, particularly in the absence of a thorough implementation initiative. In response to the Ontario findings, Haynes et al noted, Government-mandated adoption often results in high rates of reported compliance without true behavior change. 26 Two recent papers from the UK and Spain also support a similar discrepancy between reported compliance and meaningful compliance that is, between ticking boxes and using the Checklist effectively arising from centrally mandated use without work to promote the buy-in of clinicians.27,28 The authors of the Ontario study acknowledged the challenges associated with mandated use.24 In an accompanying editorial, Lucien Leape suggested, The likely reason for the failure of the surgical checklist [was] that it was not actually used. 29 The study did not measure compliance, which is akin to a drug trial with no measure of how many participants actually took the drug. The findings of this study add an important contribution to our understanding of the role of the Checklist. It is, and always has been, just a new tool to facilitate process improvement. Tools only work if used and, indeed, used well. A New Zealand perspectiveThe WHO Surgical Safety Checklist is used in the majority of surgical cases in New Zealand, in every government hospital and in the vast majority of private facilities. However, although adoption of the Checklist is widespread, a recent survey has shown that use is not consistent, and that there is considerable variability in participation across professional groups.30 This is likely to undermine the Checklists potential benefits and there is ongoing effort to evaluate barriers to compliance with administration of the Checklist and to engagement of OR teams in the process, and to identify ways in these barriers can be broken down.Since participation in the original WHO Checklist study,11 the University of Auckland Group has maintained a long-term focus on studying these matters. Utilising direct observations by trained collaborators, they have demonstrated variable compliance with administration of the three Checklist domains (Sign In, Time Out, Sign Out) and the associated Checklist items in a milieu where all Checklist domains are initiated and led by the circulating nurse from a paper copy of the Checklist. For example, an audit published in 201131 quantified compliance in the Auckland District Health Board (DHB) OR suite that participated in the original WHO study. Several years after completion of the study, there was good compliance with administration of the Sign In and Time Out domains (99% and 94% respectively), but the Sign Out domain was administered on only 2% of occasions. There was substantial variation in compliance with administration of the individual Checklist items, with some being articulated in 100% of cases, while others were used on as few as 27% of occasions. A second audit in the same operating suite some two years later reported little change in these compliance data, although the Sign Out domain had improved to 22% of occasions.32Another concerning outcome of both studies was the finding that engagement of the OR teams (surgeons, nurses, and anaesthetists) in the process was poor, even when a liberal definition of team engagement was used; at least one member of the team must have ceased all activity apart from attending to the Checklist for the team to be considered engaged. For example, during Time Out when all three teams were invariably present, engagement of all teams was only seen on 14% of occasions.32 Similarly, during Sign In, when the nursing and anaesthesia teams were invariably present (and surgeons almost always absent), engagement of both teams present was only seen on 39% of occasions. It was also telling that in 300 Checklist domains observed there was not one instance where all staff (every member of every team) in the OR were properly engaged in Checklist administration.Considerable thought has been given to identifying the reasons for the various problems identified in the above studies.Omission of Sign Out appeared attributable to the fact that it was not as clearly linked to an identifiable OR event as the other two Checklist domains. There was thus no naturally occurring aide-m\u00e9moire to signal that Sign Out should be initiated.31Selectivity in Checklist item administration appeared attributable to value judgments by administering staff as to which items were most important, or to perceptions that some questions might elicit a petulant response. For example, during Sign In, Checklist items with obvious face validity (those related to patient identity and the nature of the surgical procedure) were administered in 100% of cases. In contrast, checks on whether an airway problem was anticipated, or whether the surgeon was available, were administered in approximately 25% of cases.31 One item (the question about the anaesthetic machine check) typically elicited an irritable response and was the least-often administered (20% of cases). The latter illustrates the potential for negativity where the Checklist queries practices that a team might consider are culturally engrained or immutably embedded in their practice.Poor team engagement appeared primarily attributable to distractions by other concurrent tasks. For example, anaesthetists were prone to continuing with tasks like intravenous line insertion while the nurse administered Sign In, and surgeons were prone to continue to arrange the operating field while the nurse administered Time Out. Such disengagement by senior clinicians proved demotivating to the nurses, and there was a tendency for the Checklist administration to be truncated, but for tick-boxes to be checked anyway to indicate compliance.33 This practice has been noted in other New Zealand surveys.34Strategies to address all of these issues have been conceived and are in the process of being rolled out across Auckland DHB. A policy to link Sign Out to completion of the first swab and instrument count has brought clarity and consistency to the timing of this domain. After consultation with staff, all domains of the Checklist have been modified in order to remove some redundant items and to clarify the meaning of others. Most significantly, a radical change in the administration paradigm has been introduced. Paper Checklists and their associated tick boxes have been abandoned, and the Checklist now appears in all ORs as three large wall charts (one for each domain) that can be read from a distance. The anaesthetist leads the Sign In domain, and the surgeon leads the Time Out domain; the obvious logic being that placing the team most prone to disengagement in charge of administering the relevant domain is likely to ensure they remain engaged. The use of this system in the Counties Manukau DHB ORs appeared to result in better team engagement.32Airline pilots do not tick boxes on forms when they use a checklist. The Checklist was never intended to be used to record compliance with key processes it was intended to improve compliance with these processes. Changing to a shared leadership paradigm and abandoning the ticking of boxes should make that explicit. The impact of these changes on compliance and engagement in the first Auckland DHB OR suite to roll them out is being audited, and it is hoped that the Auckland DHB experience may inform decisions regarding Checklist practice being considered by other DHBs across the country. These changes have been applauded and endorsed by the Commission, which has taken steps to ensure that they are reflected positively in the relevant national Quality and Safety Marker.35Briefings and debriefings for surgical teamsIn the 1970s, investigators discovered that human error accounted for 70% of all crashes in aviation, and that the majority of these consisted of failures in leadership, team coordination and decision-making. 36 Communication failures are also the primary source of human error in the OR: in the US, the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) reports communication as the root cause in more than 75% of operative and postoperative sentinel events.37,38 Team briefings and debriefings have been used routinely in air forces and the aviation industry for decades, and more recently as part of NASAs Crew Resource Management (CRM), to combat these difficulties in communication in the cockpit. The introduction of briefings and debriefings to the OR has been more recent, but their value is becoming increasingly clear.Einav and colleagues found surgical briefings reduced the number of nonroutine events per operation by 25% (from 2.1 to 1.6 events) and increased the number in which no nonroutine event was observed at all.39 Lingard et al reported a decrease in communication failures in the OR (late, inaccurate, unresolved, or exclusive communications) from 3.95 per procedure before introduction of briefings to 1.31 after.40A 2012 study in a large medical centre in Michigan found that briefings and debriefings were a practical and effective strategy to surface potential surgical defects. 41 Using the Safety Attitudes Questionnaire, Makary and colleagues found briefings accounted for a reduction in OR staffs perception of risk for wrong-site surgery, and improved perceived collaboration.42Teams also report improvements in efficiency with briefings and debriefings, in contrast to some perceptions to the contrary.43 For example, a Johns Hopkins study found preoperative briefings were associated with a 19% reduction in communication breakdowns in the OR, a 31% reduction in unexpected delays, and an 82% reduction in surgeon-reported unexpected delays.44In the UK, use of both checklist and briefing CRM techniques reduced list time to the point one orthopaedic surgeon commented he had increased his list from four to five hip replacements.45BriefingsBriefings are used to share important information between different team members and groups to orient them around the tasks ahead, and to anticipate potential unexpected events or deviations from normal practice. Einav and colleagues observe, Surgical teams\u2026are frequently not familiar with all of the available data and may be only partially informed about the surgical plan. 39 Briefings are a simple, short verbal interchange involving the whole operating team prior to commencement of a list, designed to ensure the team members have shared mental models and interpretations of plans, priorities, and potential hazards to patients. Their readiness and cohesion as a team is thereby increased.46Figure 3 below shows a recommended structure for briefings, which can be tailored to individual local practice and context.Figure 3: Structuring a briefing. DebriefingsDebriefings, used by flight crews since World War Two, are a form of post-action review. They are the systematic process of sharing observations and interpretations of team processes and performance after the operation be it military or surgical is complete.47 Debriefings enable teams to take the time to reflect and learn as a group from a real-time situation. After a list is complete, a team shares what went well and what didnt go to plan, what can be learnt and what can be improved, and provide a forum to say thank you or simply, well done.Figure 4 shows a recommended structure for debriefings, which can be tailored to individual local practice and context.Figure 4: Structuring a debriefing. Complexity, autonomy and teamworkBriefings and debriefings complement the use of the Checklist, and as explained above, several major studies have shown the benefit of more comprehensive initiatives that incorporate various aspects of improving teamwork, communication and the reliability of process into surgical practice. The value of this becomes clear if one reflects on some basic principles of human performance in complex systems. Human error is inevitable particularly under stressful conditions .48 The prime objective of most checklists is to mitigate this inevitability. However, at the heart of the WHO initiative is something much more fundamental than simply avoiding mistakes. 49 Checklists are a way of bridging the simple, the complicated and the complex, of promoting uniformity in key practices, and of welding a team together around the needs of the patient before them.In The Checklist Manifesto,50 Gawande draws from Zimmerman and Glouberman51 to describe and make clear this distinction between simple, complicated and complex situations using the example of an error during the excision of a rare kind of tumour (see Box 2).Box 2: Kinds of situations and perioperative examples (adapted from running text in Gawande A. The Checklist Manifesto) Example Perioperative examples Simple Baking a cake from a mix there is a recipe Anaesthetic machine check; ensuring there are sufficient units in the blood bank for a foreseeable complication Complicated Sending someone to the moon iterable, steps can be established, a series of problems surmounted, but no straightforward recipe exists Removal of an adrenal gland containing a pheochromocytoma Complex Organic, and not iterable, like raising a child. Expertise is valuable, but most certainly not sufficient...[and] outcomes remain highly uncertain. 50 Ensuring the team is sufficiently in sync to respond rapidly and adequately to an accidentally torn vena cava Healthcare is, overall, a complex system. A surgical operation in itself should be a complicated process rather than a complex one. In some cases it should be a simple process and certainly there are common aspects of all surgical operations that are just a matter of process that is simple but essential. A prime objective of the Checklist is to get these simple and complicated processes right, every time.In the example from Gawande, during Sign In the Checklist item prompted him to mention the potential for large blood loss; this reminded the nurse to check with the blood bank; there she found that units of packed red blood cells were missing, and this problem was addressed before it occurred. This is an example of getting a simple process right.The Checklist aims to do more than this. In fact, it isnt strictly just a checklist, and it is certainly not designed to dumb down surgery or anaesthesia. Instead, it is a tool that asks clinicians to think, collaborate and plan around their patients, that also includes some important items to check. The expertise of our teams is not in doubt, but there are ever-present challenges to good teamwork in the OR: traditional training; fear of speaking out; power gradients; silo thinking; unstable teams; and shifting leadership. Good teamwork and communication become increasingly important as situations move from the routine and simple or complicated into the unexpected and complex. It is when decisions have to be made quickly without the benefit of regular practice that lives can be saved or lost by the way in which the team works as a team. In Gawandes example, he believes that when the emergency occurred, not just the retrieved units, but also the teamwork and intimacy generated by the process of using the Checklist contributed to effective and coordinated efforts that were successful in saving a life as the patient lost almost his entire volume of blood into his abdomen within 60 seconds.50Willingness is all. In New Zealand, where informality is key, we have a unique opportunity to build on that informality and more rapidly tap the Checklists power to help us better communicate as a team around anaesthetised patients needs, rather than around spurious or outdated hierarchies and perceived rights to practise autonomously. Autonomy, based on authority, is outmoded healthcare today. It is reasonable for patients to expect that teams will work together to implement evidence-based medicine, and that appropriate tools will be used to improve the reliability of processes. When asked, patients support the use of the Checklist.34 Good teamwork and communication avoids harm, saves lives, and improves efficiency,52-54 and so do simple tools to improve processes through checking.Venous thromboembolism (VTE), surgical safety and the ChecklistThe WHO Surgical Safety Checklist was always intended to be modifiable and tailored to the processes, methods and contexts of the countries and facilities where it is used. Ensuring that adequate VTE prophylaxis has taken place before skin incision is a core part of the Checklist as adapted for the New Zealand context, as it is for the NHS Checklist in England and Wales, and elsewhere.55,56 The implications of VTE prophylaxis are different in different areas Asia, for example, where reported rates are very low.57Despite the evidence, and the availability of clinical practice guidelines for the last twenty years, and the clear arguments for risk assessment screening and prophylaxis, effective VTE prophylaxis remains underused or variably used in New Zealand operating theatres.The Health Quality & Safety Commissions June 2014 Perioperative Mortality Review Committee report showed a PE-associated mortality rate in New Zealand of 8.7 per 100,000 patients who underwent an elective or waiting list procedure.58 About one in ten patients experiencing a PE will die as a result of their PE.59,60 Thats about one death from PE in every 11,500 procedures in this country.The risk of VTE increases tenfold in patients admitted to hospital, with contributing factors including general ill health or comorbidities, reduced mobility, smoking, and poor fluid intake. Major surgical procedures (particularly orthopaedic and other high-risk operations) are further risk factors, but patients who had short or minor procedures have also developed fatal PE. The incidence of PE is related to age Australian data show peak incidence of DVT and PE in the 75\u201379 year old age group but those aged 55\u201359 still contributed more than half the numbers of the older group. New Zealand estimates are lacking, but total hospital inpatient expenditure on VTE in Australia in 2008 was estimated at AUD 81.2 million, with each case of VTE costing in excess of $10,000.61Recurrence of proximal DVT occurs in up to 30% of patients within ten years of a first episode of venography-confirmed DVT, as does postphlebitic syndrome.62 DVT alone is still an issue, as it can lead to complication after complication.63Often surgeons can falsely assume anaesthetists have overseen DVT prophylaxis, and conversely.64Prevention and screening are crucial treatment of PE is difficult, and with fatal PE, 70% of patients die within three hours of onset of symptoms.63 Appropriate options for thromprophylaxis include pharmacological methods, such as the use of anticoagulants, and mechanical measures, such as compression stockings or intermittent pneumatic compression devices (IPC). Patients are an important part of their own care, and it is important to keep them informed of more general measures such as drinking enough water, keeping active, and wearing compression stockings postoperatively. A combination of these thromboprophylactic techniques has been shown to reduce the risk of DVT and both fatal and non-fatal PE by more than 60%.65 The choice of thromboprophylaxis is less important than the need to consider it in every patient and implement some reasonable strategy in those who are at risk. Therefore, the New Zealand Checklist simply asks, Has the plan for VTE prophylaxis during the operation been carried out? As clinicians, it is worth reflecting on the fact that this question might matter to us if and when we become patients.ConclusionEffective teamwork, communication, and a high degree of reliability in process (including, notably, VTE prophylaxis) in surgical practice are crucial to reduce instances of perioperative harm. There is strong evidence that engaged and effective use of the WHO Surgical Safety Checklist can reduce patient harm, and briefings and debriefings can add to these gains while simultaneously improving efficiency. The Health Quality & Safety Commissions Safe Surgery NZ programme is designed to ensure that the excellent outcomes sought for surgical patients in New Zealand are actually achieved. The Commission is grateful for the work undertaken by clinicians and DHBs to date.

Summary

Abstract

New Zealand appears to have a relatively high rate of perioperative adverse events. The Health Quality & Safety Commissions Safe Surgery NZ programme was introduced to address the rates of perioperative harm in New Zealand by promoting proper and effective use of the World Health Organization (WHO) Surgical Safety Checklist, and by encouraging use of operating room (OR) team briefings and debriefings. Venous thromboembolism prophylaxis is a key part of the checklist as deployed in New Zealand ORs, but it remains underused or variably used as well. Communication and teamwork are critical to improving patient safety and efficiency in the OR, and these interventions have demonstrated effectiveness in building and melding effective teams.

Aim

Method

Results

Conclusion

Author Information

Will Perry, General surgery trainee, Royal Australasian College of Surgeons, and member, Health Quality & Safety Commission Safe Surgery NZ Advisory Board; Ian Civil, Surgeon, Auckland City Hospital, and clinical lead, Health Quality & Safety Commission Safe Surgery NZ Programme; Simon Mitchell, Head of Department of Anaesthesiology, University of Auckland, and consultant anaesthetist, Auckland City Hospital; Carl Shuker, Principal advisor, publications, Health Quality & Safety Commission, Wellington; Alan Merry, Chair of the Board of the Health Quality & Safety Commission; and head of the School of Medicine at the University of Auckland.

Acknowledgements

Correspondence

Alan F Merry, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland.

Correspondence Email

a.merry@auckland.ac.nz

Competing Interests

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