Patient safety in aesthetic surgery

Published on 22/05/2015 by admin

Filed under Plastic Reconstructive Surgery

Last modified 22/05/2015

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CHAPTER 5 Patient safety in aesthetic surgery

Mark Jewell

Much of my inspiration to write and teach about patient safety comes from Lucian Leape MD, my professor of pediatric surgery at the University of Kansas. Dr Leape ultimately left Kansas and went to Harvard School of Public Health, where he focused on patient safety and the ways that mistakes and errors in healthcare delivery could be minimized. Dr Leape was also one of the authors of Crossing the Quality Chasm1 book which defined key quality issues in healthcare delivery. My thinking has been influenced by Steve Spear PhD and Mark Graban, who have gone beyond Dr Leape’s Institute of Medicine book, To Err is Human2 by applying aspects of the Toyota Production System and Lean Manufacturing to healthcare delivery.3,4 While immediate focus has been on how to make the delivery of healthcare safer, there are other widespread defects of dignity, comfort, satisfaction and wasteful allocation of precious resources that will take longer to improve.

In writing this chapter, I also looked to other areas where there have been remarkable advances in safety and defined processes to accomplish outcomes. When one looks at the data, as of January 2009, there has not been a fatality in United States domestic air carriers due to an accident for the preceding 24 months. This accomplishment relates to the application of CRM (crew resource management) processes for safety. This is centered around pre-flight briefings/debriefings, working with checklists, and dealing with errors. The recent effectiveness of CRM was proven in a crash of US Airways flight 1549 (January 2009) into New York’s Hudson River in which all passengers and crew survived, largely on the ability of the pilot and crew to manage the scenario of power loss at takeoff due to bird strikes.

Whether it is a manufacturing (Toyota Production System, Lean Manufacturing) or aviation-based (CRM) process for the development of a patient safety, there are two different, yet effective processes that can be adapted to produce excellent programs that will make a difference in your clinic and surgical facility.

The process of patient safety

While we are concerned about serious episodes in healthcare delivery that involve harm to patients, the effective remedy is not to browbeat those who deliver care by demanding that they give safer care. What is needed is a fundamental redesign of the process and ways to cross as the book mentions, the “quality chasm” in delivering both quality and safety.

If one looks for comparisons in other areas of American industry, large hospitals compare nicely with the likes of General Motors and Ford. Quality improvement in both GM/Ford and large hospitals is an episodic adventure, goal-oriented, and too often, a “special campaign” that lacks support from the workers. Although, progress has been made in some areas, there seems to be sometimes a greater focus on the “look what we have done” instead of this is how we do something well, time and time again. The presence of an unknown individual with a clipboard on the surgical unit usually heralds yet another ill-conceived quality or safety initiative.

There are divergent approaches to quality improvement and patient safety in medical care. For individuals who work in hospitals, there is a distinct Joint Commission of the Accreditation of Healthcare Organizations (JCAHO) “JCAHO-mindset“ regarding policies, processes, and procedures about patient safety that seem to interfere with how surgeons function and how staff thinks that an operating room should function in the real world. For individuals who work in out of hospital environments, including office based surgery units, there seems to be less preoccupation with a “JCAHO boogeyman” and more on how patient safety and care quality can be improved with each patient interaction. Currently, a majority of patient care is rendered in facilities that are outside of a “JCAHO-blessed” workplace. Published reports in the literature substantiate that outcomes are as good or better in out-of-hospital surgical facilities that are accredited by other organizations.5

Too often in the JCAHO, approach to providing solutions for patient safety, important components of safety and quality are overlooked. For instance, the fixation with the “time out” exercise before starting surgery only covers a single dimension of a “surgical destination,” that says what procedure is being performed and the surgical site. What’s missing here is the really important stuff, like a status check of the patient in terms of “being ready for surgery.” I cannot think of a surgeon or the captain of an airliner ready for takeoff who would be angered if a subordinate gave them a status report that covered the requisites of prophylactic antibiotics having been administered, DVT prophylaxis, warming blanket to prevent hypothermia, and the implants that you specified are in the room. Otherwise, the “time out” does not allow for effective communication in a team-oriented workplace.6

There is literally no way in large hospital settings to stop a faulty process once it has been placed in motion. On the other hand, there is a reliance on alternative processes called “work-arounds” to remedy a faulty process. We all have been in the uncomfortable position of having a surgery underway and discover that needed items such as implants are nowhere to be found, or that the patient did not receive prophylactic antibiotics. If this occurred in a Japanese factory, a worker would pull the Andon cord to stop the production line when a defect was noted in order to stop the line and prevent defective work from occurring.

All plastic surgeons want to avoid the downward spiral of complications, disfigurement, disability, re-operations, emotional distress, claims for professional liability, and increased regulatory oversight. If we look to other industries, namely aviation and Toyota automotive, there have been developed surprisingly effective processes to improve quality, minimize mistakes, and change a culture of workers.

Achievement of a superior surgical outcome should always be followed by reflection on what went right and what mistakes were avoided as a means of learning how to repeat such results consistently. Conversely, when failures occur, progress toward improvement is often impeded when we engage in unscientific analysis or resort to naïve investigations, reprisals, and secretive behavior that is often seen in institutions.7

For example, the problem of deep vein thrombosis with ensuing pulmonary embolism remains a vexing safety issue in all surgical patients, yet simplistic responses by state regulatory agencies to limit office-based surgery do not prevent its occurrence or morbidity/mortality in other venues. What is needed here is for the real problem to be addressed through scientific inquiry that will provide solutions. Directed research by plastic surgery foundations would be a good starting point.

Various approaches to reducing patient injuries, improving outcomes, and decreasing the cost of healthcare delivery have been suggested by organizations concerned with improvements in patient safety. Some represent Band-Aid patches to problems; others – such as careful hand-washing and safe-site surgery – are simply common sense. Ill-conceived patient safety initiatives can impair the credibility of better-conceived attempts to improve patient safety.

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