Principles of Perioperative Safety and Efficiency
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Editors
Jamal J. Hoballah Haytham M. A. Kaafarani
Surgery Surgery
American University of Beirut Massachusetts General Hospital
Medical Center Boston, MA, USA
Beirut, Lebanon
Georgios Tsoulfas
Transplantation Surgery
Aristotle University School of Medicine
Thessaloniki, Greece
ISBN 978-3-031-41088-8 ISBN 978-3-031-41089-5 (eBook)
https://doi.org/10.1007/978-3-031-41089-5
© Springer Nature Switzerland AG 2024
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We dedicate this textbook to our patients, to
whom we pledge every day to provide with
the safest and highest quality care
that we can.
Foreword
It gives me great pleasure to write this foreword to Principles of Perioperative
Safety and Efficiency, as this text represents many different elements of the surgical
experience. This is a tremendous example of the remarkable success of the Dr. Pon
Fund International Chapter Opportunity program, which is named for Pon
Satitpunwaycha, MD, FACS, whose generous donation through the American
College of Surgeons (ACS) International Relations Committee has sponsored edu-
cational courses by ACS chapters around the world. The textbook is based on the
“Principles of Perioperative Safety and Efficiency” course, which was offered in
July 2018 in Beirut, Lebanon, by the Lebanese ACS Chapter, supported by a Dr.
Pon Fund award. The enthusiastic participation in that course highlighted the need
to address, safeguard, and promote principles of perioperative safety and efficiency.
The entire perioperative process impacts successful surgical outcomes.
Despite various national and global safety initiatives, perioperative adverse
events remain alarmingly high, and this is especially notable in hospitals in low- and
middle-income countries, which may lack the resources to address the factors lead-
ing to untoward events. This textbook aims to teach healthcare providers the funda-
mental standards of perioperative safety and efficiency. This text is appropriate not
only for surgeons, but also for anesthesiologists, residents of many specialties,
medical students, nurses, hospital administrators, and other members of the health-
care team. Many will derive benefit from multiple chapters, including those focused
on informed consent in the digital era, cost containment, checklists, medication
errors, management of challenging patients, surgical site infections, handling of
specimens, error reporting, and data-driven safety and quality measurements.
In my role at the ACS, I continue to focus on our 110-year-old motto, “To Heal
All with Skill and Trust.” The principles espoused in this text are central to our mis-
sion. I am pleased at the collaborative approach taken by surgeons around the world
to advance ACS initiatives and improve the care of all our patients.
Finally, I would like to extend my congratulations to Jamal J. Hoballah, MD,
MBA, FACS; Haytham M. A. Kaafarani, MD, MPH, FACS; and Georgios Tsoulfas,
MD, PhD, FACS for their efforts in the coordination and collaboration necessary to
convene these extraordinary surgeon authors. Moreover, I thank each of them for
their commitment to the International Relations Committee of the ACS, each having
served in leadership roles.
vii
viii Foreword
I am confident that this text will be a valuable resource to surgeons and health-
care workers in all practice settings.
American College of Surgeons Patricia L. Turner
Chicago, IL, USA
Preface
“You must know, my pupils, that operative surgery is divided into two parts: one where the
operation is performed safely, and one, on the other hand, where lethal complications arise.”
Albucasis, 1000 AD, On Surgery & Surgical Instruments
Surgery is a high-hazard field. Despite all the technological advances, periopera-
tive mortality and morbidity rates remain high. Despite decades of the patient safety
movement, wrong-site surgery still happens. Despite awareness, surgical fires and
intraoperative deaths still occur. The journey toward zero preventable harm to surgi-
cal patients is long but worthwhile.
It is with great pride that we bring you the first perioperative safety textbook. The
textbook is comprehensive, covering multiple areas of safety and quality of the sur-
gical patient, from preoperative to intraoperative and postoperative care. In this text-
book, experts in surgical, medical, and anesthesia safety have come together to
bring you the latest in safety science and the latest evidence in high-reliability sci-
ence and have applied it to surgery in order to ensure surgical patients always
receive the highest quality and safest care possible.
We hope this textbook serves as a valuable reference to the millions of nurses,
physicians, administrators, and healthcare providers who have dedicated their lives
to safeguarding surgical patients worldwide.
Beirut, Lebanon Jamal J. Hoballah
Thessaloniki, Greece Georgios Tsoulfas
Boston, USA Haytham M. A. Kaafarani
ix
Contents
Part I Perioperative Optimization
1 Human Factors and Principles of Patient Safety:
The James Reason Model�������������������������������������������������������������������������� 3
Ryan Howard and Justin B. Dimick
2 Preoperative Testing in the Era of Cost Containment:
Is There a Limit?���������������������������������������������������������������������������������������� 17
Georgios Tsoulfas
3 Preventing Never Events: Checklists, Timeouts, Debriefings,
and Skin Marking�������������������������������������������������������������������������������������� 29
George Molina and Alex Haynes
4
Reducing Perioperative Medication Errors: How to Build Safer
Systems�������������������������������������������������������������������������������������������������������� 49
Petra Khoury and Ulfat Usta
5 Managing the Patient on Antiplatelet, Anticoagulation,
Beta Blockers, Angiotensin-Converting Enzyme Inhibitors,
Angiotensin-Receptors Blockers: The Anesthesia Perspective�������������� 69
Cynthia Karam, Wissam Maroun, and Marie T. Aouad
6
Reducing Surgical Site Infections������������������������������������������������������������ 87
Kamal M. F. Itani and Gentian Kristo
7 Perioperative Deep Vein Thrombosis Prophylaxis���������������������������������� 103
Mohammad Rachad Wehbe, Charbel F. Matar, Ali Taher,
and Jamal J. Hoballah
8 Handling Pacemakers and Implantable Cardioverter
Defibrillators in the Operating Room������������������������������������������������������ 123
Mohammad Sabra and Marwan M. Refaat
9
Traffic, Attire, and Distractions in the Operating Room ���������������������� 133
Chrysanthos D. Christou, Jamal J. Hoballah, and Georgios Tsoulfas
10
Handling Surgical Specimens to Decrease Errors in Pathology������������ 155
Fouad Boulos and Michel Attieh
xi
xii Contents
11
Blood Transfusion Safety in the Operating Room���������������������������������� 169
Nathan D. Neilsen, Roman Dudaryk, and Daniel Dante Yeh
Part II System Design and Improvement
12 Detecting and Reporting Errors, Complications,
and Adverse Events������������������������������������������������������������������������������������ 201
Majed El Hechi and Haytham M. A. Kaafarani
13
Simulation Technical Training to Improve Safety in the OR���������������� 217
Rana M. Higgins and Marc A. de Moya
14 Teamwork and Communication Simulation to
Improve Safety in the OR�������������������������������������������������������������������������� 229
Jamie L. Sparling and Jeffrey B. Cooper
15 Implementing Crew Resources Management
Principles to Improve Perioperative Safety �������������������������������������������� 251
Abdulelah Alhawsawi and M. Sofia Macedo
16
Peer Review of Perioperative Adverse Events ���������������������������������������� 269
Lydia R. Maurer, Elizabeth Mort, and Haytham M. A. Kaafarani
17
Enhanced Recovery After Surgery Protocols������������������������������������������ 277
Timothy E. Newhook and Thomas A. Aloia
18 “I Can’t Ventilate!” Intraoperative Anesthesia Safety
Events and Airway Management�������������������������������������������������������������� 295
Marwan Sarkis Rizk, Sarada Eleswarpu, and Chakib Maurice Ayoub
19
“Don’t Yell at Me!” Disruptive Behavior in the OR ������������������������������ 315
Julia R. Coleman and Richard Schulick
20 “Code Red!” Preventing and Managing Fire and Smoke
Hazards in the OR ������������������������������������������������������������������������������������ 327
Wilton C. Levine and Yasmine Tameze
21 “I Got Stuck!” Blood Exposure in the OR:
Prevention and Management of Sharp Injuries
and Infectious Disease Exposure�������������������������������������������������������������� 339
Tala Ballouz, Carine Sakr, and Nesrine A. Rizk
22
“I’m Missing a Sponge!” New Techniques in the
Prevention of Foreign Body Retention���������������������������������������������������� 357
Scott E. Regenbogen and Samantha J. Rivard
23
Principles of Perioperative Safety and Quality on the Global Stage���� 371
Meena Nathan Cherian, Jyotsna Agarwal, Raymond R. Price,
Janet Martin, Adrian W. Gelb, and Davy Cheng
24
The Role of the American College of Surgeons in Advancing
Perioperative Safety and Efficiency �������������������������������������������������������� 397
Julia R. Coleman and Patricia L. Turner
Index�������������������������������������������������������������������������������������������������������������������� 407
Contributors
Jyotsna Agarwal Department of Anesthesiology and Pain Medicine, Hamdard
Institute of Medical Sciences and Research, New Delhi, India
Abdulelah Alhawsawi Novo Genomics, Riyadh, Saudi Arabia
Thomas A. Aloia Oncology Services, Maternal Health and Perinatal Medicine,
Ascension, Houston, TX, USA
Marie T. Aouad Department of Anesthesiology, American University of Beirut
Medical Center, Beirut, Lebanon
Michel Attieh Department of Anatomical Pathology and Laboratory Medicine,
American University of Beirut Medical Center, Beirut, Lebanon
Chakib Maurice Ayoub Department of Anesthesiology, Duke University school
of Medicine, Durham, NC, USA
Tala Ballouz Department of Internal Medicine, Division of Infectious Diseases,
American University of Beirut, Beirut, Lebanon
Fouad Boulos Department of Pathology and Immunology, Washington University
in St. Louis, St. Louis, MO, USA
Davy Cheng Schulich School of Medicine & Dentistry, Western University,
London, ON, Canada
Meena Nathan Cherian Department of Global Health New Challenges, Geneva
Foundation for Medical Education and Research, Versoix, Switzerland
Chrysanthos D. Christou Center for Research and Innovation in Solid Organ
Transplantation, Department of Transplantation Surgery, Aristotle University
School of Medicine, Thessaloniki, Greece
Julia R. Coleman Department of Surgery, University of Colorado–Denver,
Aurora, CO, USA
Jeffrey B. Cooper Department of Anesthesia, Critical Care, & Pain Medicine,
Massachusetts General Hospital, Boston, MA, USA
Department of Anesthesia, Harvard Medical School, Boston, MA, USA
Center for Medical Simulation, Boston, MA, USA
xiii
xiv Contributors
Justin B. Dimick Frederick A. Coller Distinguished Professor and Chair
Department of Surgery, Michigan Medicine, University of Michigan, Ann
Arbor, MI, USA
Roman Dudaryk Department of Anesthesiology, University of Miami,
Miami, FL, USA
Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL, USA
Sarada Eleswarpu Department of Anesthesiology, Duke University school of
Medicine, Durham, NC, USA
Majed El Hechi Department of Surgery, Massachusetts General Hospital,
Boston, MA, USA
Adrian W. Gelb Department of Anesthesia and Perioperative Care, University of
California San Francisco, San Francisco, CA, USA
Alex Haynes Department of Surgery and Perioperative Care, University of Texas
Austin, Austin, TX, USA
Rana M. Higgins Department of Surgery, Medical College of Wisconsin,
Milwaukee, WI, USA
Jamal J. Hoballah Department of Surgery, American University of Beirut Medical
Center, Beirut, Lebanon
Ryan Howard Department of Surgery, University of Michigan, Ann Arbor, MI, USA
Kamal M. F. Itani Department of Surgery, Veterans Affairs Boston Healthcare
System, West Roxbury, MA, USA
Department of Surgery, Boston University, Boston, USA
Harvard Medical School, Boston, MA, USA
Haytham M. A. Kaafarani Department of Surgery, Division of Trauma,
Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital,
Boston, MA, USA
Cynthia Karam American University of Beirut Medical Center, Beirut, Lebanon
Petra Khoury Health and Care Department, International Federation of Red Cross
Red Crescent, Geneva, Switzerland
Gentian Kristo Department of Surgery, Veterans Affairs Boston Healthcare
System, West Roxbury, MA, USA
Harvard Medical School, Boston, MA, USA
Wilton C. Levine, M.D. Department of Anesthesia, Critical Care and Pain
Medicine, Massachusetts General Hospital, Boston, MA, USA
M. Sofia Macedo Center for National Health Insurance, Ar Rabi, Riyadh,
Saudi Arabia
Contributors xv
Wissam Maroun American University of Beirut Medical Center, Beirut, Lebanon
Janet Martin Department of Anesthesia & Perioperative Medicine, Epidemiology
& Biostatistics, London Health Sciences Centre, London, ON, Canada
Charbel F. Matar Department of Internal Medicine, University of Connecticut,
Farmington, CT, USA
Lydia R. Maurer Department of Surgery, Massachusetts General Hospital,
Boston, MA, USA
George Molina Brigham and Women’s Hospital, Boston, MA, USA
Elizabeth Mort Department of Medicine, Massachusetts General Hospital,
Boston, MA, USA
Marc A. de Moya Division of Trauma and Acute Care Surgery, Medical College
of Wisconsin, Milwaukee, WI, USA
Nathan D. Neilsen Section of Transfusion Medicine and Therapeutic Pathology,
Division of Pulmonary, Critical Care, and Sleep Medicine, University of New
Mexico School of Medicine, Albuquerque, NM, USA
Timothy E. Newhook Department of Surgical Oncology, Division of Surgery, MD
Anderson Cancer Center, Houston, TX, USA
Raymond R. Price Center for Global Surgery, University of Utah, Salt Lake
City, UT, USA
Marwan M. Refaat Department of Internal Medicine/ Division of Cardiology,
American University of Beirut, Faculty of Medicine and Medical Center (AUBMC),
Beirut, Lebanon
Department of Biochemistry and Molecular Genetics, American University of
Beirut Faculty of Medicine, Beirut, Lebanon
Scott E. Regenbogen Department of Surgery, University of Michigan, Ann
Arbor, MI, USA
Samantha J. Rivard Department of Surgery, University of Michigan, Ann
Arbor, MI, USA
Marwan Sarkis Rizk Department of Anesthesiology, American University of
Beirut, Beirut, Lebanon
Nesrine A. Rizk Department of Internal Medicine, Division of Infectious Diseases,
American University of Beirut, Beirut, Lebanon
Mohammad Sabra Department of Internal Medicine/Division of Cardiology,
Henry Ford Health, Detroit, MI, USA
Carine Sakr Department of Employee Health, American University of Beirut
Medical Center, Beirut, Lebanon
xvi Contributors
Richard Schulick University of Colorado Department of Surgery, Aurora, CO, USA
University of Colorado Cancer Center, Aurora, CO, USA
University of Colorado Anschutz Medical Campus, Aurora, CO, USA
Jamie L. Sparling Department of Anesthesia, Critical Care, & Pain Medicine,
Massachusetts General Hospital, Boston, MA, USA
Department of Anesthesia, Harvard Medical School, Boston, MA, USA
Ali Taher Division of Hematology and Oncology, Department of Internal
Medicine, American University of Beirut Medical Center, Beirut, Lebanon
Yasmine Tameze, M.D. Department of Anesthesia, Critical Care and Pain
Medicine, Massachusetts General Hospital, Boston, MA, USA
Georgios Tsoulfas Department of Transplantation Surgery, Center for Research
and Innovation in Solid Organ Transplantation, Aristotle University School of
Medicine, Thessaloniki, Greece
Center for Research and Innovation in Solid Organ Transplantation, Department
of Transplantation Surgery, Aristotle University School of Medicine,
Thessaloniki, Greece
Patricia L. Turner American College of Surgeons, Chicago, IL, USA
Ulfat Usta Pharmacy Department, Aman Hospital, Doha, Qatar
Mohammad Rachad Wehbe Division of Vascular Surgery, Department of
Surgery, University of Rochester, Rochester, NY, USA
Daniel Dante Yeh Denver Health Medical Center, Denver, CO, USA
Abbreviations
AAMC Association of American Medical Colleges
ABA American Board of Anesthesiology
ABC Assessment of blood consumption [score]
ABMS American Board of Medical Specialties
ACC American College of Cardiology
ACCP American College of Chest Physicians
ACE Angiotensin-converting enzyme
ACEi Angiotensin-converting enzyme inhibitors
ACGME Accreditation Council for Graduate Medical Education
ACS American College of Surgeons
ACS NSQIP American College of Surgeons National Surgical Quality
Improvement Program®
ACS/SIS American College of Surgeons and the Surgical Infection Society
ADD(s) Automated dispensing device(s)
ADE(s) Adverse drug event(s)
AEIs Accredited Education Institutes
AEs Adverse events
AGS American Geriatrics Society
AHA American Heart Association
AHRQ Agency for Healthcare Research and Quality
AHTR(s) Acute hemolytic transfusion reaction(s)
AI Artificial intelligence
AIDS Acquired immunodeficiency syndrome
AIMS Anesthesia Information Management Systems
ALT Alanine transaminase
AMR Antimicrobial resistance
AMT Anesthesia medication template
anti-HBc Hepatitis B core antibodies
anti-HBs Hepatitis B surface antibodies
AORN Association of periOperative Registered Nurses
APSF Anesthesia Patient Safety Foundation
aPTT Activated partial thromboplastin time [test]
ARB Angiotensin receptor blockers
ARM Anesthetic-related mortality
xvii
xviii Abbreviations
ASA American Society of Anesthesiologists
ASCO American Society for Clinical Oncology
ASH American Society of Hematology
ASHP American Society of Health-System Pharmacists
ASPE Association of Standardized Patient Educators
ASPF Anesthesia Patient Safety Foundation
ASPiH Association for Simulated Practice in Healthcare
ATC Acute traumatic coagulopathy
ATLS Advanced Trauma Life Support [course]
AV Atrioventricular
BBP(s) Blood-borne pathogen(s)
BID Twice a day [dose]
BMI Body mass index
BPMH Best Possible Medication History
CABG Coronary artery bypass grafting
CAP College of American Pathologists
CAT Critical administration threshold
CAT Competency assessment tool
CBC Complete blood count
CDC Centers for Disease Control and Prevention
CDIs Clostridium difficile infections
CDS Clinical decision support
CHSE Certified Healthcare Simulator Educator
CICV Cannot intubate, cannot ventilate
CIED(s) Cardiac implantable electronic device(s)
CISB Critical incident stress debriefing
CMS Centers for Medicare and Medicaid Services
CoC Commission on Cancer
COT Committee on Trauma
CPAP Continuous positive airway pressure
CPC Committee on Perioperative Care
CPOE Computerized physician order entry [system(s)]
CRM Crew resource management
CRM Crisis resource management
CRT Cardiac resynchronization therapy
CS Clinical skills
CSPS Council on Surgical and Perioperative Safety
CUSP Comprehensive unit-based safety program
CVR Chest X-ray
CXR Chest radiograph
DAC Difficult airway cart
DAM Difficult airway management
DASH Debriefing Assessment for Simulation in Healthcare [program]
DI Difficult intubation
DMV Difficult mask ventilation
