PRINCIPLES OF SAFE

SURGERY

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Preamble
Surgical care has been an essential component of
health systems worldwide for > than a
century.Although there have been major improvemnts
over the last few decades, the quantity and safety of
surgical care has been dismayingly variable in every
part of the world. The Safe Surgery Saves Lives
initiative aims to change this by raising the standards
that patients anywhere can expect.

Dr. Atul Gawande.

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Box 2: Five facts about surgical safety
1. Complications after inpatient operations occur in up to 25% of
patients.
2. The reported crude mortality rate after major surgery is 0.5
5%.
3. In industrialized countries nearly half of all adverse events in
hospitalized patients are related to surgical care.
4. At least half of the cases in which surgery led to harm are
considered to be preventable.
5. Known principles of surgical safety are inconsistently applied
even in the most sophisticated settings.

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Points of action

Surgical site infection prevention

Safe anaesthesia
Safe surgical teams
Measurement of surgical services

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Adverse event
Injury caused by medical management rather than the underlying condition of the
patient
Prolongs hospitalization, produces a disability at discharge, or both
Classified as preventable or unpreventable
Negligence
Care that falls below a recognized standard of care
Standard of care is considered to be care a reasonable physician of similar knowledge,
training, and experience would use in similar circumstances
Near miss
An error that does not result in patient harm
Analysis of near misses provides the opportunity to identify and remedy system
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failures
Sentinel event

An unexpected occurrence involving death or serious physical or psychological injury

The injury involves loss of limb or function

This type of event requires immediate investigation and response

Other examples

Hemolytic transfusion reaction involving administration of blood or blood products having major blood
group incompatibilities

Wrong-site, wrong-procedure, or wrong-patient surgery

A medication error or other treatment-related error resulting in death

Unintentional retention of a foreign body in a patient after surgery

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Libby Zion was an 18-year-old woman who died after being admitted to the
New York Hospital with fever and agitation on the evening of October 4,
1984. Her father, Sidney Zion, a lawyer and columnist for the N.Y. Daily
News, was convinced that his daughter's death was due to inadequate
staffing and overworked physicians at the hospital and was determined to
bring about changes to prevent other patients from suffering as a result of
the teaching hospital system. Due to his efforts to publicize the
circumstances surrounding his daughter's death, Manhattan District
Attorney Robert Morgenthau agreed to let a grand jury consider murder
charges. Although the hospital was not indicted, in May 1986, a grand jury
issued a report strongly criticizing "the supervision of interns and junior
residents at a hospital in NY County." 7
As a result, New York State Health Commissioner David Axelrod convened
a panel of experts headed by Bertrand M. Bell, a primary care physician at
Albert Einstein College of Medicine who had long been critical of the lack
of supervision of physicians-in-training, to evaluate the training and
supervision of doctors in New York State. The Bell Commission
recommended that residents work no more than 80 hours per week and
no more than 24 consecutive hours per shift, and that a senior physician
needed to be physically present in the hospital at all times. These
recommendations were adopted by New York State in 1989. In 2003, the
Accreditation Council on Graduate Medical Education followed by
mandating that all residency training programs adhere to the reduced
work hour schedule.

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Box 5: Ten essential objectives for safe surgery
Objective 1. The team will operate on the correct patient at the correct site.
Objective 2. The team will use methods known to prevent harm from anaesthetic
administration, while protecting the patient from pain.
Objective 3. The team will recognize and effectively prepare for life-threatening
loss of airway or respiratory function.
Objective 4. The team will recognize and effectively prepare for risk of high blood loss.
Objective 5. The team will avoid inducing an allergic or adverse drug reaction known to be a
significant risk to the patient.
Objective 6. The team will consistently use methods known to minimize risk of surgical site
infection.
Objective 7. The team will prevent inadvertent retention of sponges or
instruments in surgical wounds.
Objective 8. The team will secure and accurately identify all surgical specimens.
Objective 9. The team will effectively communicate and exchange critical patient
information for the safe conduct of the operation.
Objective 10. Hospitals and public health systems will establish routine surveillance
of surgical capacity, volume and results.

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Sign in before induction of anaesthesia, ideally with surgeon present, but not essential
Verbally verify, review with the patient when possible:
a. Patient identity
b. Procedure and site
c. Consent for surgery
d. Operative site is marked if appropriate (involving left or right distinction)
e. Pulse oximeter is on the patient and functioning
Review between anaesthetist and checklist coordinator:
f. Patients risk of blood loss. If >500ml in adults or >7ml/kg in children, it is recommended to have
at least 2 large bore intravenous lines or a central line before surgical incision and fluids or blood
available
g. Airway difficulty or aspiration risk. Where a potentially high-risk airway is identified, at a minimum
the approach to anaesthesia should be adjusted accordingly, emergency equipment must be
accessible and a capable assistant should be physically present during induction. Symptomatic
active reflux or a full stomach should also be handled with a modified plan
h. Known allergies - all members of team need to be aware
i. Anaesthesia safety checks complete (equipment, medications, emergency medications, patients
anaesthetic risk)

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2. Time out after induction and before surgical incision, entire team
a. Each team member introduces him/herself by name and role
b. Pause to confirm correct operation for correct patient on correct site.
Anaesthetist, nurse and surgeon
should all individually confirm agreement, plus the patient if awake
c. Review anticipated critical events
i. Surgical critical/unexpected steps, operative duration, anticipated
blood loss
ii. Anaesthetic patient specific concerns, for example, intention to use
blood products, co-morbidities
iii. Nurses confirm sterility of instruments and discuss equipment
issues/concerns
d. Confirm prophylactic antibiotics where required, was given within the
60 minutes prior to skin incision. If not
given and required, administer prior to incision. If >60 minutes, consider
re-dosing the patient
e. Essential imaging displayed as appropriate
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3. Sign out during or immediately after wound closure, before
moving the patient out of the operating room, whilst
surgeon still present
a. Confirm operation performed and recorded
b. Check instrument, sponge/swab and needle counts are
complete. Where numbers do not reconcile the team should be
alerted and take steps to investigate
c. Check surgical specimens labelled correctly
d. Highlight equipment issues
e. Verbalize plans or concerns for recovery and postoperatively,
especially any specific risks

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Pragmatic challenges
Duplication with existing checklists leading to
irritation and checklist fatigue
Time consuming, inconvenient
Inappropriate timing
Poor communication
Unfamiliarity, confusion, who should prompt the items
Absence of key team members
Using the checklist as a tick box exercise

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Attitudes

Denial that routine tasks can be forgotten

Dismissive attitudes, lack of engagement
Hierarchy in the operating theatre discouraging
open communication
Embarrassment about introductions
Lack of support from leaders or managers

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Resources
Lack of resources such as marker pens,
antibiotics and pulse oximeters

Underlying processes of care

Lack of antibiotic policies, protocols
No routine swab, needle or instrument counts

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Tips
Leadership
Implementation and staff training
Timing of briefing of briefing and surgical checks
Resources and documentation
Data collection and feedback

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Figure 1. The WHO Surgical Safety Checklist
PATIENT HAS CONFIRMED
IDENTITY
SITE
PROCEDURE
CONSENT
SITE MARKED/NOT APPLICABLE
ANAESTHESIA SAFETY CHECK COMPLETED
PULSE OXIMETER ON PATIENT AND FUNCTIONING
DOES PATIENT HAVE A: KNOWN ALLERGY?
NO
YES
DIFFICULT AIRWAY/ASPIRATION RISK?
NO
YES, AND EQUIPMENT/ASSISTANCE AVAILABLE
RISK OF >500ML BLOOD LOSS
(7ML/KG IN CHILDREN)?
NO
YES, AND ADEQUATE INTRAVENOUS ACCESS
AND FLUIDS PLANNED
SIGN IN
Before induction of anaesthesia 17
 Time out: Before Incision
CONFIRM ALL TEAM MEMBERS HAVE INTRODUCED THEMSELVES BY NAME AND ROLE
SURGEON, ANAESTHESIA PROFESSIONAL AND NURSE VERBALLY CONFIRM
PATIENT
SITE
PROCEDURE
ANTICIPATED CRITICAL EVENTS SURGEON REVIEWS:
WHAT ARE THE CRITICAL OR UNEXPECTED STEPS, OPERATIVE DURATION,
ANTICIPATED BLOOD LOSS?
ANAESTHESIA TEAM REVIEWS:
ARE THERE ANY PATIENT-SPECIFIC CONCERNS?
NURSING TEAM REVIEWS:
HAS STERILITY (INCLUDING INDICATOR RESULTS) BEEN CONFIRMED? ARE THERE
EQUIPMENT ISSUES OR ANY CONCERNS?
HAS ANTIBIOTIC PROPHYLAXIS BEEN GIVEN
WITHIN THE LAST 60 MINUTES?
YES
NOT APPLICABLE
IS ESSENTIAL IMAGING DISPLAYED?
YES
NOT APPLICABLE
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Sign Out: Before the patient leaves
Nurse verbally confirms with the team:
The name of the procedure recorded
That instrument, sponge and needle
Counts are correct (or not applicable)
How the specimen is labelled
(Including patient name)
Whether there are any equipment problems to be addressed
Surgeon, anaesthesia professional and nurse review the key concerns
for recovery and management of this patient

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