Department of Surgery, San Francisco Veterans Affairs Medical Center, San Francisco, CA 94121, USA.
World J Gastroenterol. 2012 Dec 14;18(46):6712-9. doi: 10.3748/wjg.v18.i46.6712.
The three surgical patient safety events, wrong site surgery, retained surgical items (RSI) and surgical fires are rare occurrences and thus their effects on the complex modern operating room (OR) are difficult to study. The likelihood of occurrence and the magnitude of risk for each of these surgical safety events are undefined. Many providers may never have a personal experience with one of these events and training and education on these topics are sparse. These circumstances lead to faulty thinking that a provider won't ever have an event or if one does occur the provider will intuitively know what to do. Surgeons are not preoccupied with failure and tend to usually consider good outcomes, which leads them to ignore or diminish the importance of implementing and following simple safety practices. These circumstances contribute to the persistent low level occurrence of these three events and to the difficulty in generating sufficient interest to resource solutions. Individual facilities rarely have the time or talent to understand these events and develop lasting solutions. More often than not, even the most well meaning internal review results in a new line to a policy and some rigorous enforcement mandate. This approach routinely fails and is another reason why these problems are so persistent. Vigilance actions alone have been unsuccessful so hospitals now have to take a systematic approach to implementing safer processes and providing the resources for surgeons and other stakeholders to optimize the OR environment. This article discusses standardized processes of care for mitigation of injury or outright prevention of wrong site surgery, RSI and surgical fires in an action-oriented framework illustrating the strategic elements important in each event and focusing on the responsibilities for each of the three major OR agents-anesthesiologists, surgeons and nurses. A Surgical Patient Safety Checklist is discussed that incorporates the necessary elements to bring these team members together and influence the emergence of a safer OR.
手术患者安全事件中的三个问题，即手术部位错误、手术器械遗留（RSI）和手术火灾，均为罕见事件，因此难以对其在复杂现代手术室（OR）中的影响进行研究。这些手术安全事件发生的可能性及其风险的严重程度均不明确。许多医护人员可能从未亲身经历过这些事件之一，而且针对这些主题的培训和教育也很少。这种情况导致人们错误地认为医护人员不会发生此类事件，或者如果发生了，医护人员凭直觉就知道该怎么做。外科医生不关注失败，而且通常会考虑好的结果，这使他们忽视或低估了实施和遵循简单安全实践的重要性。这种情况导致这三个事件持续低频率发生，并且难以引起足够的兴趣来提供解决方案。个别医疗机构很少有时间或人才去理解这些事件并制定持久的解决方案。通常，即使是最善意的内部审查也只是在政策中增加了一行内容，并规定了严格的执行要求。这种方法经常失败，这也是这些问题持续存在的另一个原因。仅采取警惕行动是不成功的，因此医院现在必须采取系统的方法来实施更安全的流程，并为外科医生和其他利益相关者提供资源，以优化手术室环境。本文讨论了在以行动为导向的框架中，针对减轻伤害或彻底预防手术部位错误、RSI 和手术火灾的护理标准化流程，阐明了每个事件中的重要战略要素，并重点关注手术室中三个主要角色——麻醉师、外科医生和护士的责任。讨论了手术患者安全检查表，该检查表纳入了必要元素，可将这些团队成员聚集在一起，并影响更安全手术室的出现。
