WHO Guidelines for Safe Surgery - Atul Gawande
World Alliance for Patient Safety
WHO Guidelines for Safe Surgery
(First Edition)
The WHO Guidelines for Safe Surgery, First Edition, is intended to be issued as a Second Edition in 2009.
At present it is important for countries and organizations to note that the guidelines represent a consensus of international experts and up to date technical information on safe surgery across the world.
The guidelines are being implemented for testing purposes in several hospitals across the six WHO regions and changes may be made to some of the technical content of the chapters in light of results.
We welcome formal feedback on these guidelines. Feedback is invited using the AGREE methodology
WHO/IER/PSP/2008.08-1E
? World Health Organization 2008
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Printed in the United States of America
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Table of contents
Section I. Introduction
7
The problem: Complications of surgical care have become a major cause of death and
disability worldwide
8
The Safe Surgery Saves Lives Challenge: Identifying solutions
10
Transformation of risk during anaesthesia
The `time out' or `surgical pause'
Use of a checklist for central line insertion
The Safe Surgery Saves Lives approach
12
Improvement through the Safe Surgery Saves Lives programme
13
Organization of the guidelines
15
Section II. Ten essential objective for safe surgery: Review of the evidence and
recommendations
19
Objective 1: The team will operate on the correct patient at the correct site.
21
The Universal Protocol
Step 1. Verification
Step 2. Marking
Step 3. `Time out'
Recommendations
Objective 2: The team will use methods known to prevent harm from administration of
anaesthetics, while protecting the patient from pain.
27
Patterns of avoidable morbidity and mortality during anaesthesia
Approaches to improving the safety of anaesthesia
Evidence on monitoring with pulse oximetry and capnography
Expert opinion
Controlled trials
Incident reporting
Inference from data on anaesthesia mortality
Other considerations on oximetry and capnography
Conclusion
Preparation for and delivery of anaesthesia
Facilities
Anaesthesia equipment
Gas supplies in anaesthesia
Monitoring
Ancillary equipment and medications
Infrastructure, supplies and care standards
Recommendations
Objective 3: The team will recognize and effectively prepare for life-threatening loss of airway
or respiratory function.
45
Incidence of difficult and failed airway management
Airway assessment
Thyromental distance
Mallampati classification
Management of the airway
Face-mask ventilation
Supraglottic airway ventilation
Endotrachial intubation
4
Fibre-optic intubation Aspiration of gastric contents Recommendations
Objective 4: The team will recognize and effectively prepare for risk of high blood loss. 57 Resuscitation of hypovolaemic patients Prevention of blood loss Management of blood loss Recommendations
Objective 5: The team will avoid inducing an allergic or adverse drug reaction for which the
patient is known to be at significant risk.
63
Types of adverse reactions
Causes of error in delivery of perioperative medications
Recommendations
Objective 6: The team will consistently use methods known to minimize the risk for surgical
site infection.
69
Pathogenesis and microbiology
Prevention and surveillance of surgical site infections
Definitions of surgical site infection
Superficial incisional surgical site infection
Deep incisional surgical site infection
Organ?space surgical site infection
Methods of scoring infection
Surveillance of surgical site infections
Inpatients
Post-discharge
Risk factors
Blood glucose and risk of infection
Oxygen tension and temperature in the perioperative period
Presurgical skin disinfection
Alcoholic compounds
Chlorhexidine
Iodophors
Triclosan and chloroxylenol
Octenidine
Special cases for decontamination
Vaginal and uterine surgery
Digestive-tract surgery
Antibiotic prophylaxis
Prophylaxis in children
Subacute bactieral endocarditis prophylaxis in patients undergoing
surgical procedures
Minimizing contamination in the operating room
Guaranteeing sterility of surgical instruments: sterility indicators
Recommendations
Objective 7: The team will prevent inadvertent retention of instruments or sponges in
surgical wounds.
115
General criteria for counting
Sponge count
Sharps count
Instrument count
Documentation of counts
5
Count discrepancies Methodical wound exploration before closure Recommendations
Objective 8: The team will secure and accurately identify all surgical specimens.
121
Recommendations
Objective 9: The team will effectively communicate and exchange critical information on the
patient.
123
Team culture and its effects on safety
Patterns of communication breakdown
Reducing communication breakdown during surgery
Use of checklists to improve safety and communication
Record-keeping
Recommendations
Objective 10: Hospitals and public health systems will establish routine surveillance of
surgical capacity, volume and results.
133
Feasibility and implications of measurement
Infrastructure
Economic considerations
Positive incentives
Negative incentives
Case mix and risk adjustment
Current measures in surgery
Volume
Outcome
Capacity
Surgical surveillance: Surgical vital statistics for systems-level evaluation
Basic surgical vital statistics
The number of operating rooms in each country
The number of surgical procedures performed in operating rooms in
each country
The numbers of trained surgeons and trained anaesthesia
professionals in each country
Number of deaths on the day of surgery
Number of in-hospital deaths after surgery
Intermediate surgical vital statistics
Advanced surgical vital statistics
Surgical surveillance: Basic patient measures at hospital and practitioner
levels
Day-of-surgery and postoperative in-hospital mortality rates
Surgical site infections
The Surgical Apgar Score: a simple outcome score for surgery
Findings from international pilot site
Future directions of surgical surveillance
Recommendations
Summary of Recommendations
151
Section III. WHO Surgical Safety Checklist
153
Section IV. Implementation manual for the WHO Surgical Safety Checklist
157
Authors and contributors
167
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