Patient Safety and organizational Safety Culture in Surgery: A Need of an Hour in the developing countries
Importance of patient safety in surgery
AbstractEvery year, more than 200 million surgeries are performed around the world, and recent statistics show that adverse event rates for surgical pathologies remain unacceptably high, despite several national and global patient safety initiatives over the last decade. Patient safety is diverse and highly complicated in nature, with several critical components. Although concern for patient safety is fundamental in health care practice, its transition into knowledge is comparatively recent, and hence patient safety may be deemed a "new" field. Current surgical safety guidelines and checklists are generic and not adapted to specific patient concerns and risk factors in surgical subspecialties. All surgical practitioners and health care organizations must therefore become better aware of the fundamental context of patient safety, actively participate in endeavors to integrate patient safety measures in daily practice, and foster a patient safety culture. The purpose of this review article is to outline patient safety in surgical techniques that should be adopted and implemented.
2. America IO, Staff IO. Crossing the quality chasm: a new health system for the 21st century.
3. Sammer CE, Lykens K, Singh KP, Mains DA, Lackan NA. What is patient safety culture? A review of the literature. Journal of nursing scholarship. 2010 Jun;42(2):156-65.
4. Colla JB, Bracken AC, Kinney LM, Weeks WB. Measuring patient safety climate: a review of surveys. BMJ Quality & Safety. 2005 Oct 1;14(5):364-6.
5. Donaldson MS, Corrigan JM, Kohn LT, editors. To err is human: building a safer health system.
6. Singer SJ, Gaba DM, Falwell A, Lin S, Hayes J, Baker L. Patient safety climate in 92 US hospitals: differences by work area and discipline. Medical care. 2009 Jan 1:23-31.
7. Nicklin W, Mass H, Affonso DD, O'Connor P, Ferguson-Paré M, Jeffs L, Tregunno D, White P. Patient safety culture and leadership within Canada's Academic Health Science Centres: towards the development of a collaborative position paper. Nursing Leadership (Toronto, Ont.). 2004 Mar 1;17(1):22-34.
8. Hofer TP, Kerr EA, Hayward RA. What is an error?. Effective Clinical Practice. 2000 Nov;3(6).
9. Bernstein M, Hebert PC, Etchells E. Patient safety in neurosurgery: detection of errors, prevention of errors, and disclosure of errors. Neurosurgery Quarterly. 2003 Jun 1;13(2):125-37.
10. Bates DW, Cullen DJ, Laird N, Petersen LA, Small SD, Servi D, Laffel G, Sweitzer BJ, Shea BF, Hallisey R, Vander Vliet M. Incidence of adverse drug events and potential adverse drug events: implications for prevention. Jama. 1995 Jul 5;274(1):29-34.
11. Robertson L. 1998. Injury epidemiology. New York: Oxford University Press.
12. Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, Hebert L, Newhouse JP, Weiler PC, Hiatt H. The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II. New England journal of medicine. 1991 Feb 7;324(6):377-84.
13. Health & Safety Commission. ACSNI human factors study group: third report. Organising for safety. London: HMSO. 1993.
14. Angelos P. Surgical ethics and the challenge of surgical innovation. The American Journal of Surgery. 2014 Dec 1;208(6):881-5.
15. Reason J. Human error: models and management. Bmj. 2000 Mar 18;320(7237):768-70.
16. Sickbert-Bennett EE, Weber DJ, Gergen-Teague MF, Sobsey MD, Samsa GP, Rutala WA. Comparative efficacy of hand hygiene agents in the reduction of bacteria and viruses. American journal of infection control. 2005 Mar 1;33(2):67-77.
17. Pittet D, Allegranzi B, Storr J, Donaldson L. 'Clean care is safer care': the global patient safety challenge 2005–2006. International Journal of Infectious Diseases. 2006 Nov 1;10(6):419-24.
18. Pittet D, Donaldson L. Challenging the world: patient safety and health care-associated infection. International journal for quality in health care. 2006 Feb 1;18(1):4-8.
19. Ahmed QA, Memish ZA, Allegranzi B, Pittet D. Muslim health-care workers and alcohol-based handrubs. Lancet. 2006 Mar 25;367(9515):1025-7.
20. Jha AK, Prasopa-Plaizier N, Larizgoitia IA, Bates DW. Patient safety research: an overview of the global evidence. BMJ Quality & Safety. 2010 Feb;19(1):42-7.
21. Bates DW, Larizgoitia I, Prasopa-Plaizier N, Jha AK. Global priorities for patient safety research. Bmj. 2009 May 14;338.
22. Hospital Healthcare Europe. 2008. Clean Care is Safer Care: linking healthcare behaviour to health policy.[online]Available at:
23. Sax H, Allegranzi B, Uckay I, Larson E, Boyce J, Pittet D. 'My five moments for hand hygiene': a user-centred design approach to understand, train, monitor and report hand hygiene. Journal of Hospital infection. 2007 Sep 1;67(1):9-21.
24. Milne JK, Bendaly N, Bendaly L, Worsley J, FitzGerald J, Nisker J. A measurement tool to assess culture change regarding patient safety in hospital obstetrical units. Journal of obstetrics and gynaecology Canada. 2010 Jun 1;32(6):590-7.
25. Makary MA, Sexton JB, Freischlag JA. Teamwork in the operating room: teamwork in the eye of the beholder. J Am Coll Surg. 2005.
26. Cederholm S, Hill G, Asiimwe A, Bate A, Bhayat F, Persson Brobert G, Bergvall T, Ansell D, Star K, Norén GN. Structured assessment for prospective identification of safety signals in electronic medical records: evaluation in the health improvement network. Drug safety. 2015 Jan;38(1):87-100.
27. Gu X, Itoh K. A pilot study on safety climate in Chinese hospital. Journal of patient safety. 2011 Dec 1;7(4):204-12.
28. World Health Organization. World alliance for patient safety: forward programme 2008-2009. World Health Organization; 2008.
29. MacDavitt K, Chou SS, Stone PW. Organizational climate and health care outcomes. The Joint Commission Journal on Quality and Patient Safety. 2007 Nov 1;33(11):45-56.
30. Yamalik N. Quality systems in dentistry Part 1. The increasing pressure for quality and implementation of quality assurance and improvement (QA/I) models in health care. International dental journal. 2007 Oct 1;57(5):338-46.
31. Yamalik N. Quality systems in dentistry part 2. Quality assurance and improvement (QA/I) tools that have implications for dentistry. International dental journal. 2007 Dec 1;57(6):459-67.
32. Ruchlin HS, Dubbs NL, Callahan MA, Fosina MJ. The role of leadership in instilling a culture of safety: lessons from the literature. Journal of Healthcare Management. 2004;49(1):47
33. Yamalik N. The responsibilities and rights of dental professionals 2. Professional responsibilities. International dental journal. 2006 Jun;56(3):168-70.
34. Health & Safety Commission. ACSNI human factors study group: third report. Organising for safety. London: HMSO. 1993.
35. Hunter T, Birmingham J. Preventing readmissions through comprehensive discharge planning. Professional case management. 2013 Mar;18(2):56-63.
36. Nieva VF, Sorra J. Safety culture assessment: a tool for improving patient safety in healthcare organizations. BMJ quality & safety. 2003 Dec;12(suppl 2):ii17-23.
37. Agrawal A. Medication errors: prevention using information technology systems. British journal of clinical pharmacology. 2009 Jun;67(6):681.
38. Halligan M, Zecevic A. Safety culture in healthcare: a review of concepts, dimensions, measures and progress. BMJ quality & safety. 2011 Apr 1;20(4):338-43.
39. Lippi G, Blanckaert N, Bonini P, Green S, Kitchen S, Palicka V, Vassault AJ, Mattiuzzi C, Plebani M. Causes, consequences, detection, and prevention of identification errors in laboratory diagnostics. Clinical chemistry and laboratory medicine. 2009 Feb 1;47(2):143-53.
40. Pronovost PJ, Weast B, Holzmueller CG, Rosenstein BJ, Kidwell RP, Haller KB, Feroli ER, Sexton JB, Rubin HR. Evaluation of the culture of safety: survey of clinicians and managers in an academic medical center. BMJ Quality & Safety. 2003 Dec 1;12(6):405-10.
41. DuPree E, Anderson R, McEvoy MD, Brodman M. Professionalism: a necessary ingredient in a culture of safety. The Joint Commission Journal on Quality and Patient Safety. 2011 Oct 1;37(10):447-55.
42. Mehrotra S, Basukala S, Devarakonda S. Effective lighting design standards impacting patient care: a systems approach. Journal of Biosciences and Medicines. 2015;3(11):54.
43. Larsen D, Peters H, Keast J. Using real time patient feedback to introduce safety changes. Nursing Management. 2011 Sep 27;18(6).
44. Kant S, Patnaik SK, Kapoor P, Singh MM, Mehrotra S, Basukala S, Ranyal RK, Yadav P. Application of 3D Music inventory control technique for the controlled drugs in intensive care unit of a tertiary care hospital. International Journal of Research Foundation of Hospital and Healthcare Administration. 2015 Jun 1;3(1):5-9.
45. DesHarnais SI, Nash DB. Reforming way medical students and physicians are taught about quality and safety. Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine. 2011 Nov;78(6):834-41.
This work is licensed under a Creative Commons Attribution 4.0 International License.
Copyright and Open Access Policy
This journal provides immediate open access to its content on the principle that making research freely available to the public supports a greater global exchange of knowledge.
JSSN applies the Creative Commons Attribution (CC BY) license to all works we publish. Under the CC BY license, authors retain ownership of the copyright for their article, but authors allow anyone to download, reuse, reprint, distribute, and/or copy articles in JSSN, so long as the original authors and source are cited. No permission is required from the authors or the publishers.
Article by JSSN is licensed under a Creative Commons Attribution 4.0 International License.
Based on a work at http://www.jssn.org.np/index.php?journal=jssn.