lego surgical safety checklist
TRANSCRIPT
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TheWHO SurgicalSafety ChecklistA brief history (with Lego)
built byDr Thom O'Neill
Raigmore Hospital NHS Highland
Scotland
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The Checklist
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Atul Gawande
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Why do people die from simple
errors?
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The Super-Specialist
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No more Masters
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The Burden Of Knowledge
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Human Fallibility
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Ignorance
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Ineptitude
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How do we reduce harm?
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The Checklist
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ComplexityTheory
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The Glasgow Subway:Simple
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The Early London
Underground:Complicated
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Complex
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Construction
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TheMaster Builder
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Too much for one
individual
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Complicated
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Aviation
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Individual Skill
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Complex
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The Hudson RiverEmergency
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Article 126
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Healthcare
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Where to start?
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Who should lead it?
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Is the correct site marked?
Initial barriers
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Anaesthetic machine
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Prophylaxis
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Drugs checked?
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Expected blood loss
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Eight major cities
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Large and small centres
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35% 47%
Complications Deaths
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SURPASS Trial47% reduction mortality
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Checklist in 2008Flat death rates pre-20080.06% fall in rates per year sinceEst. 9000 lives saved
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Ontario study9% fall in deaths(0.71% to 0.65%)Design problems (20% ophth)Government mandatedMeasured at 3 months
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Mandate without training
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Medics
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Central lines
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Pre-hospital
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