Assignment 3.03 Safe Surgery

HAWRA'A ALSHAKHS 215027049 \ SN: 71

Assignment 3.03 Safe surgery saves life

Teamwork has an important role in minimizing the errors. First, we need to define what a teamwork is. It means that people will try to cooperate, using their individual skills and providing constructive feedback, despite any personal conflict between individuals. Second, there are many points in which teamwork has a role in reducing errors. Teamwork enhances learning process. When people work together on a team that will maximize shared knowledge in the workplace and helps them to learn new skills they can use for the rest of their career. What you have learned from your individual experiences is entirely different from your coworkers. Also team members enjoy working

together and that helps them to concentrate more in their tasks because they enjoy and love what they do. In addition to that, team members come from varied backgrounds and have different work styles. This creates the most successful work because they will share their experiences and knowledge.
The systems in reporting surgical errors. The errors that occur either do or do not harm patients and reflect numerous problems in the system. Many countries now collect data about the wrong patient receiving an invasive procedure. Incident reporting system is an organization's ability to learn from error. There are two models have been developed using root cause analysis principles. The first model is called the London Protocol. It takes the team through each of the steps of a clinical investigation. The other model is The Veterans Affairs National Center. It is for patient safety of the United States department of Veterans Affairs and it uses a structured approach of root
cause analysis (RCA). The aim of this model is to evaluate and to analyze severe adverse events and develop system improvements to prevent their recurrence.
Adverse effects mean undesirable secondary effect like when a treatment goes beyond the desired effect and causes a problem.

The treatment could be a medication, surgical procedure or some kind of therapy has an undesirable secondary effect which occurs in addition to the desired therapeutic effect. The causes of adverse effects vary for each patient, and depend largely on their general health, the state of their disease, age, weight, and gender. There are 3 main causes of adverse effects in procedural care. They are poor infection control, inadequate patient's management and failure of health care provider to communicate effectively before, during and after procedure. In poor infection control, a study found that surgical wound infections consider as the second largest category of adverse events. However, administration of prophylactic antibiotics has reduced the incidence of postoperative infections. In the second cause which is inadequate patient's management, the operating room and environment involve intensely complex activities involving a range of health professionals and should always include the patient when conscious. This may explain why more adverse events are associated with surgical departments than with other hospital departments. Also there are other factors contribute in a lot of adverse events in surgical care like inadequate implementation of protocols, poor leadership; poor teamwork, conflict between different departments/groups within the organization, inadequate training and preparation of staff, inadequate resources, lack of evidence based practice, poor work culture, overwork and lack of a system for managing performance. In the third cause, Miscommunication is one of the biggest problems in the operating environment. Miscommunication has been responsible for the wrong patients having surgery, patients having operations on the wrong side or site, and the wrong procedure being

performed.
Failure to communicate changes in the patient’s condition and failure to administer prophylactic antibiotics have also resulted in adverse events.
Effectiveness of mortality and morbidity meetings in contribution to safe patient care. Many hospitals will have surgical review meetings, often called mortality and morbidity meetings. These are well-established forums for discussing incidents and difficult cases and are the main peer-review method for improving future patient care. Such meetings usually provide a confidential forum for auditing surgical complications and are necessary for improving practice in a surgical department. Because patient safety is a relatively new discipline, many of these meetings have yet to adopt a blame-free systems approach for discussing errors. Instead, some remain focused on the person who made an error and use a punitive approach to discuss adverse events. Learning about errors in surgery. Mortality and morbidity meetings are a way to discuss the errors and try to prevent them in future.
The key message of the case in the coach manual. Even though there is a teamwork, it was ineffective and the surgical error was not prevented. This case shows us the importance of incident reporting. That's because the model examines multiple factors, such as communication, training, fatigue, scheduling of tasks, equipment and rules,. In this case the action of the orthopedic surgeon and the nurses should be the focus of interest and that what some models concentrates on.