Disruptive Physicians: How Behavior Can Undermine Patient Safety

Disruptive physician behavior is a pervasive threat to patient safety and a source of emotional and financial hardship on the health care system. It causes increases in medical errors, staff turnover, and risk of litigation. Behavioral problems can be symptoms of underlying issues that must be addressed, such as substance abuse, psychiatric conditions, or burnout. Reporting of disruptive behavior is low, especially by colleagues. Current methods in place in many health care systems do not adequately recognize warning signs or take appropriate corrective actions to limit the effects of disruptive physicians. Changes must be made at a system level to improve rehabilitation of problem physicians

Retained Foreign Body

Retained foreign bodies after surgeries or procedures are a rare complication with great consequences. The most commonly retained surgical items are guidewires, surgical sponges, and suture needles. The procedure at highest risk for retained foreign bodies is central venous catheterization. The literature regarding specific risk factors that increase the potential for retained surgical items varies. Evidence suggests that procedures with blood loss over 500 mL, lack of or an incorrect surgical instrument and sponge count, longer procedures, and unexpected intraoperative events all increase the risk of retained surgical items. There is conflicting evidence on the effect that elevated body mass index (BMI) or the emergent nature of a procedure has on retained surgical item risk. Interventions aimed at preventing retained foreign bodies include surgical counts, mandatory imaging after procedures, bar-coding of items used during surgery, and radiofrequency detection systems. These interventions have varying detection rates. Regardless of the safety measures used, none are perfect and a high index of suspicion must be maintained to prevent retained surgical foreign bodies

Sepsis and Septic Shock

Sepsis and septic shock are life-threatening conditions that remain an enormous burden of morbidity and mortality to millions of patients globally and cause organ dysfunction, leading to death in as many as one in four patients, often even more. Early management and appropriate treatment are essential to improve outcomes and reduce morbidity and mortality. In 2016, the Third International Consensus Definition for Sepsis and Septic Shock (Sepsis-3) defined sepsis as life-threatening organ dysfunction resulting from dysregulated host responses to infection, and defined septic shock as a subset of sepsis in which underlying circulatory, cellular, and metabolic abnormalities are profound enough to substantially increase the risk of mortality. That same year the group also implemented the application of the sequential organ failure assessment (SOFA) score over the systemic inflammatory response syndrome (SIRS) score. Sepsis in pregnancy remains a leading cause of maternal morbidity and mortality worldwide, with no current standard definition for severe sepsis for the pregnant or peripartum woman. The prevalence of pediatric septic shock is on the rise and brings with it the consequences of long-term morbidity and also death. Since the advent of programs for early recognition and treatment, mortality has decreased. Even so, globally, many children succumb to septic shock despite evidence-based care and years of research

Hypertensive disorders of pregnancy: a clinical study in a rural tertiary care centre of western Uttar Pradesh, India

Background: The aim of study was to find out the frequency and clinical outcome in hypertensive disorder of pregnancy (HDP) in a rural tertiary care centre. Hypertensive disorder of pregnancy is a commonest medical disorder which constitutes about 12-22% of all pregnancies and it is a major cause of maternal morbidity as well as mortality world wide.Methods: It is a retrospective hospital-based study to find out the clinical outcome in different hypertensive disorder of pregnancy in a rural tertiary care centre of western Uttar Pradesh.Results: Present study showed the prevalence of HDP was 4.01% among the study population. Most of the patients were primipara ,unbooked and less than 25 years of age. The most common HDP was mild preeclampsia  and HELLP was its commonest  complication.Conclusions: Hypertensive disorder of pregnancy (HDP) is still a major cause of maternal mortality and morbidity. Authors intend to aware the pregnant women regarding high risk factors of pregnancy and motivate them for regular antenatal care so that  complications of  hypertensive disorders can be  managed timely

Avoiding Fire in the Operating Suite: An Intersection of Prevention and Common Sense

The operating room (OR) is a complex environment that involves large teams and multiple competing priorities, dynamically interacting throughout the entire course of a surgical procedure. The simultaneous presence of flammable substances, volatile gases, and the frequent use of electrical current results in a potentially dangerous combination. Operating room fire (ORF) is a rare but potentially devastating occurrence. To prevent this “never event”, it is critical for institutions to establish and follow proper fire safety protocols. Adherence to proven prevention strategies and awareness of associated risk factors will help reduce the incidence of this dreaded safety event. When ORF does occur despite strict adherence to established safety protocols, the entire OR team should know the steps required to contain and extinguish the fire as well as essential measures to minimize or avoid thermal injury. If injury does occur, it is important to recognize and treat it promptly. Appropriate and honest disclosure to all injured persons and their families should be made without delay. As with all serious patient safety events, regulatory reporting and root cause determinations must take place in accordance with applicable laws and regulations. The goal of patient safety champions at each institution should be the attainment of zero incidence of ORF

Fact versus Conjecture: Exploring Levels of Evidence in the Context of Patient Safety and Care Quality

Evidence-based medicine (EBM) can be defined as the integration of optimized clinical judgment, patient values, and available evidence. It is a philosophical approach to making the best possible clinical decisions for individual patients. Based on objective evaluation and categorization of methodological design and data quality, all existing literature can be organized according to a hierarchy of “evidence quality” that helps determine the applicability and value of scientific findings in terms of clinical implementation and the potential to change existing patterns of practice. In terms of general categorization of scientific impact, randomized controlled trials (RCTs) are placed on top of the hierarchy, followed by systematic reviews of randomized controlled trials (RCTs), quasi-randomized designs, observational studies including retrospective case series, and finally case reports and expert opinion. Each study design is susceptible to certain limitations and biases, highlighting the importance of both clinical and scientific acumen of the interpreting provider. Such approach is critical to determining the value and the applicability of study recommendations in everyday practice. Evidence-based practice (EBP) has become one of the fundamental components of modern medicine and plays an indispensible role in the development (and improvement) of patient care and safety worldwide. Furthermore, organizations that create guidelines and policies for the management of specific conditions, often base the content and strength of their recommendations on the quality of evidence available to expert decision-makers. Therefore, understanding the “state of the science” upon which those recommendations are based will help guide the medical practitioner on “if, when and how” to apply evidence-based guidelines in his or her everyday medical or surgical practice. This chapter focuses on clinically relevant application of levels of scientific evidence (LSE) and the corresponding levels of clinical recommendation (LCR) in the context of care quality and safety

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Surgical and Trauma Capacity Assessment in Rural Haryana, India

Background: Trauma is a major global health problem and majority of the deaths occur in low- and middle-income countries (LMICs), at even higher rates in the rural areas. The three-delay model assesses three different delays in accessing healthcare and can be applied to improve surgical and trauma healthcare delivery. Prior to implementing change, the capacities of the rural India healthcare system need to be identified. Objective: The object of this study was to estimate surgical and trauma care capacities of government health facilities in rural Nanakpur, Haryana, India using the Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) and International Assessment of Capacity for Trauma (INTACT) tools. Methods: The PIPES and INTACT tools were administered at eight government health facilities serving the population of Nanakpur in June 2015. Data analysis was performed per tool subsection, and an overall score was calculated. Higher PIPES or INTACT indices correspond to greater surgical or trauma care capacity, respectively. Findings: Surgical and trauma care capacities increased with higher levels of care. The median PIPES score was significantly higher for tertiary facilities than primary and secondary facilities [13.8 (IQR 9.5, 18.2) vs. 4.7 (IQR 3.9, 6.2), p = 0.03]. The lower-level facilities were mainly lacking in personnel and procedures. Conclusions: Surgical and trauma care capacities at healthcare facilities in Haryana, India demonstrate a shortage of surgical resources at lower-level centers. Specifically, the Primary Health Centers were not operating at full capacity. These results can inform resource allocation, including increasing education, across different facility levels in rural India