Patient safety in the perioperative setting is determined by many interdependent factors including reliable systems, good teamwork, psychological safety, optimal communications and most crucially shared vision and goals. The necessary organizational, environmental and behavioural conditions for quality care are not new and were in fact known to Florence Nightingale as much as 150 years ago. As noted by Nightingale, and something that remains unchanged today, the greatest threat to patient safety are the frailties of the human condition, complacent attitudes and unconscious behaviours. Recognizing that error is normal and somewhat inevitable, given the complexity of modern surgery, is undoubtedly the first step to mitigating error and harm, and the basis from which to tackle variability and sub-optimal conditions to deliver quality improvement.
Alexander G. and Staggers N.(2009) A systematic review of the designs of clinical technology: Findings and recommendations for future research. Advanced Nursing Science32: 252-279.
2.
Amalberti R., Vincent C., Auroy Y. and de Saint Maurice G. ( 2006) Violations and migrations in health care: A framework for understanding and management. Quality and Safety in Health Care15(Suppl. 1): i66-i71.
3.
Berwick DM, Calkins DR, McCannon JC and Hackbath AD ( 2006) The 100 000 lives campaign: Setting a goal and a deadline for improving health care quality. The Journal of the American Medical Association295: 324-327.
4.
Beyea SC ( 2004) A critical partnership: safety for nurses and patients . AORN Journal Available at: http://findarticles.com/p/articles/mi_m0FSL/is_6_79/ai_n6076846/.
5.
Bognar A., Barach P., Johnson JK, Duncan RC, Birnbach D., Woods D., et al. (2008) Errors and the burden of errors: Attitudes, perceptions, and the culture of safety in pediatric cardiac surgical teams . Annals of Thoracic Surgery85: 1374-1381.
6.
Bosk CL, Dixon-Woods M., Goeschel CA and Pronovost PJ ( 2009) Reality check for checklists. Lancet374: 444-445.
7.
Carthey J., de Leval MR, Wright DJ, Farewell VJ and Reason JT ( 2003) Behavioural markers of surgical excellence. Safety Science41: 409-425.
8.
Catchpole KR, Giddings AE, de Leval MR, Peek GJ, Godden PJ, Utley M., et al. (2006) Identification of systems failures in successful paediatric cardiac surgery. Ergonomics49: 567-588.
9.
Catchpole KR, Giddings AE, Hirst G., Dale T., Peek GJ and de Leval MR ( 2008b) A method for measuring threats and errors in surgery . Cognition, Technology and Work10: 295-304.
10.
Catchpole KR, Giddings AE, Wilkinson M., Hirst G., Dale T. and de Leval MR ( 2007) Improving patient safety by identifying latent failures in successful operations. Surgery142: 102-110.
11.
Catchpole KR, Godden PJ, Giddings AE, Hirst G., Dale T., Utley M., et al. (2005) Identifying and Reducing Errors in the Operating Theatre. PSO12. Patient Safety Research Programme. Available at: http://pcpoh.bham.ac.uk/publichealth/psrp/publications.htm
12.
Catchpole K., Mishra A., Handa A. and McCulloch P. ( 2008a) Teamwork and error in the operating room: Analysis of skills and roles. Annals of Surgery247: 699-706.
13.
Catchpole K., Panesar S., Russell J., Tang V., Hibbert P. and Cleary K. ( 2009) Surgical Safety can be improved through Better Understanding of Incidents Reported to a National Database. Available at: http://www.nrls.npsa.nhs.uk/resources/clinical-specialty/surgery/ .
14.
Christian CK, Gustafson ML, Roth EM, Sheridan TB, Gandhi TK, Dwyer K., et al. (2006) A prospective study of patient safety in the Operating Room. Surgery139: 159-173.
15.
Choy YC ( 2006) Critical incident monitoring in anaesthesia. Medical Journal of Malaysia61: 577-585.
16.
Clarke J. and Reid J.(2009) Progressing safer surgery. Journal of Perioperative Practice19: 328-333.
17.
de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ and Boermeester MA ( 2008) The incidence and nature of in-hospital adverse events: A systematic review. Journal of Minimally Invasive Gynaecology16: 23-33.
18.
Department of Health (2000) Organisation with a Memory.
19.
Department of Health (2001) Building a Safer NHS.
20.
Department of Health (2006) Safety First: A report for Patients, Clinicians and Healthcare Managers.
21.
Department of Health (2010) Equity and Excellence: Liberating the NHS.
22.
Evans C. ( 2007) Tackling patient safety through team working: The Safer Patients Initiative. The Health Foundation. Available at: http://www.health.org.uk/news/features/tackling_patient .
23.
Fagin L. and Garelick A. ( 2004) The doctor-nurse relationship. Advances in Psychiatric Treatment10: 277-286. Available at http://apt.rcpsych.org/.
24.
Fleming M., Smith S., Slaunwhite J. and Sullivan J. ( 2006) Investigating interpersonal competencies of cardiac surgery teams. Canadian Journal of Surgery49: 22-30.
25.
Flin R. and Mitchell L. ( 2009) Eds Safer Surgery: Analysing Behaviour in the Operating Theatre. Farnham, Surrey, England: Ashgate Publishing Ltd.
26.
Flin R., Yule S., McKenzie L., Paterson-Brown S. and Maran N. ( 2006) Attitudes to teamwork and safety in the operating theatre . Surgeon4: 145-151.
27.
Francis R. ( 2010) Final Report of the Independent Inquiry into Care Provided By Mid Staffordshire NHS Foundation Trust. Available at: http://www.midstaffsinquiry.com/pressrelease.html.
28.
Gawande A. ( 2009) The Checklist Manifesto: How to Get Things Right . London, England: Profile Books .
29.
Gawande AA, Zinner MJ, Studdert DM and Brennan TA ( 2003) Analysis of errors reported by surgeons at three teaching hospitals. Surgery133: 614-621.
30.
Giles SJ, Rhodes P., Clements G., Cook GA, Hayton R., Maxwell MJ, et al. (2006) Experience of wrong site surgery and surgical marking practices among clinicians in the UK. Quality and Safety in Health Care15: 363-368.
31.
Haynes A., Weiser T., Berry WR, Lipsitz SR, Breizat A., Dellinger P., et al. (2009) A surgical safety checklist to reduce morbidity and mortality in a global population. New England Medical Journal360: 491-499.
32.
House of Commons All Party Health Committee Patient Safety Report of Session (2008-09). HC 151-I. Available at: http://www.publications.parliament.uk/pa/cm200809/cmselect/cmhealth/151 .
33.
Institute of Medicine (IOM) (2004) Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academies Press .
34.
Kennedy I. ( 2009) Bullying ‘Permeating’ Patient Care, Warns Healthcare Commission Available at: http://www.hsj.co.uk/news/workforce/bullying-permeating-patient-care-warns-healthcare-commission/2007581.article
35.
Kohn LT, Corrigan JM and Donaldson MS ( 2000) To Err is Human. Washington, DC: National Academy Press.
36.
Lewin Report ( 1970) Organisation and Staffing of Operating Departments. London : HMSO.
37.
Lingard L., Espin S., Whyte S., Regehr G., Baker GR, Reznick R., et al. (2004) Communication failures in the operating room: An observational classification of recurrent types and effects. Quality and Safety in Health Care13: 330-334.
38.
Lingard L., Reznick R., Espin S., Regehr G. and DeVito I. ( 2002) Team communications in the operating room: Talk patterns, sites of tension and implications for novices. Academic Medicine77: 232-237.
39.
Mahajan R. and Reid J.(2009) The RCoA pledges to support patient safety first. Bulletin. Royal College of Anaesthetists58: 40-42.
40.
Makary MA, Sexton JB, Freischlag JA, Holzmueller CG, Millman EA, Rowen L., et al. (2006) Operating room teamwork among physicians and nurses: Teamwork in the eye of the beholder. Journal of the American College of Surgeons202: 746-752.
41.
McDonald TB, Helmchen LA, Smith KM, Centomani N., Gunderson A., Mayer D., et al. (2009) Responding to Patient Safety Incidents: The ‘Seven Pillars’. Available at: http://qualitysafety.bmj.com/content/early/2010/02/26/qshc.2008.031633.full
42.
Mitchell L. and Flin R. ( 2008) Non-technical skills of the operating theatre scrub nurse: Literature review. Journal of Advanced Nursing63: 15-24.
43.
Mongomery Dossey B. ( 2009) Florence Nightingale: Mystic, Visionary, Healer . Philadelphia, PA: F.A. Davis Company.
44.
National Audit Office (2005) A Safer Place for Patients: Learning to Improve Patient Safety. London: The Stationery Office.
45.
National Patient Safety Agency (2010a) Never Events Framework. Available at: http://www.nelm.nhs.uk/en/NeLM-Area/News/2010-March/26/NPSA-Never-Events-Framework/.
46.
National Patient Safety Agency (2010b) 10 for 2010: Five Steps to Safer Surgery. Available at: http://www.nrls.npsa.nhs.uk/resources/collections/10-for-2010/five-steps-to-safer-surgery/ .
47.
Nemeth C., Nunnally M., Bitan Y., Nunnally S. and Cook RI(2009) Between choice and chance: The role of human factors in acute care equipment decisions. Journal of Patient Safety5: 114-121.
48.
Nestel D. and Kidd J. ( 2006) Nurses’ Perceptions and Experiences of Communication in the Operating Theatre: A Focus Group Interview. Available at: http://www.biomedcentral.com/1472-6955/5/1.
49.
Nightingale F. ( 1860) Notes on Nursing: What it is, and what it is not . New York: D Appleton and Company . Available at: http://digital.library.upenn.edu/women/nightingale/nursing .
50.
Parker J. ( 2005) The art and science of nursing. In: Daly J, Speedy S, Jackson D, Lambert V and Lambert C (eds) Professional Nursing: Concepts, Issues and Challenges. New York: Springer Publishing Company.
51.
Patient Safety First (2010a) Five Steps to Improving Perioperative Communications and Teamwork using the WHO Surgical Safety Checklist. Available at: http://www.patientsafetyfirst.nhs.uk/ashx/Asset.ashx?path=/Interventionsupport/WHO%20Checklist%20five%20steps .
52.
Patient Safety First (2010b) Implementing the Surgical Checklist, the Journey so far. Implementation Survey Findings. Available at: http://www.patientsafetyfirst.nhs.uk/Content.aspx?path=/interventions/Perioperativecare/.
53.
Pearse RM, Dana EC, Lanigan CJ and Pook JA ( 2001) Organisational failures in urgent and emergency surgery. A potential peri-operative risk factor. Anaesthesia56: 684-689.
54.
Pisano GP, Bohmer RMJ and Edmondson AC ( 2001) Organizational differences in rates of learning: Evidence from the adoption of minimally invasive cardiac surgery. Management Science47: 752-768.
55.
Pronovost P., Weast B., Rosenstein B., Sexton B., Holzmueller C., Paine L., et al. (2005) Implementing and validating a comprehensive unit-based safety program. Journal of Patient Safety1: 33-40.
56.
Radcliffe M. ( 2000) Doctors and nurses: New game, same result. British Medical Journal320: 1085.
57.
Reason J. ( 1990) Human Error. Cambridge: Cambridge University Press.
58.
Reason J. ( 1997) Managing the Risks of Organizational Accidents . Aldershot: Ashgate.
59.
Reason J. ( 2000) Human error: Models and management. British Medical Journal320: 768-770.
60.
Rogers SO, Gawande AA, Kwaan M., Puopolo AL, Yoon C., Brennan TA, et al. (2006) Analysis of surgical errors in closed malpractice claims at 4 liability insurers. Surgery140: 25-33.
61.
Runciman WB, Webb RK, Helps SC, Thomas EJ, Sexton EJ, Studdert DM, et al. (2000) A comparison of iatogenic injury studies in Australia and the USA. II: Reviewer behaviour and quality of care. International Journal for Quality in Health Care12: 379-388.
62.
Sedlak CA ( 2004) Nurse Safety: Have We Addressed the Risks? Available at: http://www.nursingworld.org/ojin/topic25/tpc25ntr.htm .
63.
Sexton JB, Thomas EJ and Helmreich RL ( 2000) Error, stress and teamwork in medicine and aviation: Cross sectional surveys. British Medical Journal320: 745-749.
64.
Stein L., Watts DT and Howell T. ( 1990) The doctor-nurse game revisited. New England Journal of Medicine322: 546-549.
65.
Stein LI ( 1967) The doctor-nurse game. Archives of General Psychiatry16: 699-703.
66.
Timmons S. and Reynold A. ( 2005) The doctor-nurse relationship in the operating theatre . British Journal of Perioperative Nursing15: 110-115.
67.
Timmons S. and Tanner J. ( 2004) A disputed occupational boundary: Operating theatre nurses and operating department practitioners. Sociology of Health and Illness26: 645-666.
68.
Undre S., Sevdalis N., Healey AN, Darzi SA and Vincent CA ( 2006) Teamwork in the operating theatre: Cohesion or confusion ? Journal of Evaluation in Clinical Practice12: 182-189.
69.
Verdaasdonk EG, Stassen LP, Widhiasmara PP and Dankelman J (2009) Requirements for the design and implementation of checklists for surgical processes. Surgical Endoscopy23: 715-726.
70.
Vincent C., Neale G. and Woloshynowych M. ( 2001) Adverse events in British hospitals: Preliminary retrospective record review. British Medical Journal322: 517-519.
71.
Waring J. ( 2005) Beyond blame: Cultural barriers to medical incident reporting . Social Science and Medicine60: 1927-1935.
72.
WHO (2008) WHO Surgical Safety Checklist and Implementation Manual. Available at: http://www.who.int/patientsafety/safesurgery/ss_checklist/en/index.html
73.
Wiegmann DA, Elbardissi AW, Dearani JA, Daly RC and Sundt TM ( 2007) Disruptions in surgical flow and their relationship to surgical errors: An exploratory investigation. Surgery142: 658-665.
74.
Yule S., Flin R., Paterson-Brown S. and Maran N. ( 2006) Non-technical skills for surgeons in the operating room: A review of the literature. Surgery139: 140-149.
