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406
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40. American College of Surgeons. Statement on patient safety in the operating room: team care.
https://www.facs.org/about- acs/statements/113- patient- safety. Accessed 14 Jul 2019.
41. Clancy CM, Tornberg DN.TeamSTEPPS: assuring optimal teamwork in clinical settings. Am
J Med Qual. 2007;22(3):214–7.
42. American College of Surgeons. Committee on perioperative care. https://www.facs.org/about-
acs/governance/acs- committees/committee- on- perioperative- care. Accessed 14 Jul 2019.
43. American College of Surgeons. Council on surgical and perioperative safety. https://www.ast.
org/Aboutus/CSPS_Statements/. Accessed 14 Jul 2019.
44. Houck CS, Deshpande JK, Flick RP.The American College of Surgeons Children's Surgery
Verication and Quality Improvement Program: implications for anesthesiologists. Curr Opin
Anaesthesiol. 2017;30(3):376–82.
45. Sachdeva AK. Acquisition and maintenance of surgical competence. Sem Vasc Surg.
2002;15(3):182–90.
46. Sachdeva AK, Philibert I, Leach DC, Blair PG, Stewart LK, Rubinfeld IS, etal. Patient safety
curriculum for surgical residency programs: results of a national consensus conference.
Surgery. 2007;141(4):427–41.
47. Kshirsagar RS, Chandy Z, Mahboubi H, Verma SP.Does resident involvement in thyroid surgery lead to increased postoperative complications? Laryngoscope. 2017;127(5):1242–6.
48. Loppenberg B, Cheng PJ, Speed JM, Cole AP, Vetterlein MW, Kibel AS, etal. The effect of
resident involvement on surgical outcomes for common urologic procedures: a case study of
uni- and bilateral hydrocele repair. Urology. 2016;94:70–6.
49. Vetterlein MW, Seisen T, Loppenberg B, Hanna N, Cheng PJ, Fisch M, etal. Resident involvement in radical inguinal orchiectomy for testicular cancer does not adversely impact perioperative outcomes—a retrospective study. Urol Int. 2017;98(4):472–7.
50. Jubbal KT, Echo A, Spiegel AJ, Izaddoost SA.The impact of resident involvement in breast
reconstruction surgery outcomes by modality: an analysis of 4,500 cases. Microsurgery.
2017;37(7):800–7.
51. Jubbal KT, Chang D, Izaddoost SA, Pederson W, Zavlin D, Echo A.Resident involvement
in microsurgery: an American College of Surgeons National Surgical Quality Improvement
Program analysis. J Surg Ed. 2017;74(6):1124–32.
J. R. Coleman and P. L. Turner
Index
https://t.me/med1917
A
Accordion classication, 209
Accreditation Council for Graduate Medical
Education (ACGME), 402, 403
Acquired immunodeciency syndrome
(AIDS), see Human
immunodeciency virus (HIV)
Acute hemolytic transfusion reactions
(AHTRs), 176
Acute traumatic coagulopathy (ATC), 180
Advanced Trauma Life Support (ATLS)
course, 398
Adverse drug event (ADE), 50
Adverse events (AEs), 207
intraoperative adverse events
clinical assessment, 209
occurrence, 209
Surgical Apgar Score, 210
surgical scheme, 210–212
postoperative adverse events
Accordion classication, 209
Clavien-Dindo classication, 208, 209
Agency for Health Care Research and Quality
(AHRQ), 61, 62, 203, 398
American Association of Blood Banks, 174
American Board of Medical Specialties
(ABMS), 402
American College of Cardiology /American
Heart Association
(ACC/AHA), 75, 76
American College of Chest Physicians
(ACCP) guidelines, 108
American College of Surgeons (ACS), 137
ACGME, 402, 403
evidence-based practice
ACS NSQIP, 398–400
National Recommendations, 400–402
Promotion of Collaborative Consensus
Statement, 400–402
quality improvement programs, 398
ISCR, 401
principles, 397, 398
quality and safety programs, 398
resident education, 402, 403
American College of Surgeons and the
Surgical Infection Society
(ACS/SIS), 91
American College of Surgeons National
Surgical Quality Improvement
Program (ACS NSQIP),
272, 398–400
American Society for Clinical Oncology
(ASCO), 162
American Society for Testing and Materials
(ASTM) standard, 55
American Society of Anesthesiologists
(ASA), 19, 55
American Society of Health-System
Pharmacists (ASHP), 53
Anaesthetic-related mortality (ARM), 373
Anesthesia
initiatives of quality and safety, 51, 52
prevalence, 50, 51
Anesthesia facility assessment tool
(AFAT), 389
Anesthesia information management
systems (AIMS), 207
Anesthesia medication template (AMT), 58
Anesthesia Patient Safety Foundation (ASPF),
51, 55, 230
Anesthesia safety, 377, 378
Angiotensin-converting enzyme inhibitors
(ACEi), 80–82
Angiotensin receptor blockers (ARB), 80–82
© Springer Nature Switzerland AG 2024
J. J. Hoballah et al. (eds.), Principles of Perioperative Safety and Efciency,
https://doi.org/10.1007/978-3-031-41089-5
407
408
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Index
Antimicrobial prophylaxis, 285
Arrhythmias, 128
Association for the Advancement of Blood &
Biotherapies (AABB), 174
Association of periOperative Registered
Nurses (AORN), 51, 139, 361
Atrioventricular (AV) delay, 131
Automated dispensing device (ADD), 60
B
Bar-coded sponge system, 364, 365
Beta blockers, 78–80
Blood-borne pathogens (BBP)
denition, 340
exposure risk, 344
exposure source, 344
healthcare worker, 344
incident reporting, 343, 344
needlesticks, 339
occupational exposure (see Occupational
exposure)
prevention, 352, 353
strategies, 339
wound, 343
Blood products
emergency plasma transfusion, 176, 177
emergency red blood cell transfusion,
175, 176
massive blood transfusion, 177–179
risks of transfusion
hemolytic transfusion reactions,
172, 173
nosocomial infection, 174
TACO and TRALI, 174
TRIM, 174
TTIs, 170, 171
type and screen /crossmatch, 174, 175
Blood transfusion
ATC, 180
crystalloid-based resuscitation, 179
damage control resuscitation, 179
delayed administration, 179
injured warriors, 179
military studies, 179
MTP
CAT, 183, 184
non-massive transfusion, 185
non-trauma patients, 185
over-transfusion, 183
prediction, 184, 185
resuscitation intensity, 183, 184
survival benet, 185
survival rates, 183
PROMMTT study, 180
TXA, 186, 187
VET, 181, 182
walking blood bank, 179
C
Cannot intubate, cannot ventilate (CICV),
309, 310
Cardiac implantable electronic devices (CIEDs)
emergency surgery
evaluation, 130
management, 130, 131
EMI
clinical responses, 124
denition, 124
ESU, 124, 125
surgical equipment, 125
intraoperative management, 128–130
mechanical interference, 125
postoperative management, 131
preoperative assessment
device interrogation, 126, 127
magnet application, 128
pre-anesthesia consultation, 125, 126
programming machine, 128
reprogramming, 127, 128
Cardiac resynchronization therapy (CRT),
125, 126
Centers for Disease Control and Prevention
(CDC), 87, 88, 137
Centers for Medicare and Medicaid Services
(CMS), 357
Children’s Surgery Verication and Quality
Improvement Program (ACS
CSG), 402
Classroom-based training, 222
Clavien-Dindo classication, 208, 209
Clinical decision support (CDS), 58
Coagulopathy, 177
Cognitive aids, 233–235
Cold ischemic time, 162
College of American Pathologists (CAP),
156, 162
Computer crossmatch, 175
Computerized physician order entry (CPOE)
systems, 58
Coronary artery bypass graft (CABG) surgery,
114, 115
Cost containment
clinical indication, 25
evaluation, 25
preoperative testing
blood work and procedures, 22
chest X-ray (CXR), 24
coagulation studies, 23
Index
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409
complete blood count (CBC), 23
degree of severity, 20
electrocardiogram (ECG), 22, 23
electrolytes, creatinine, glucose, 24
evidence-based decision, 21
geriatric population, 25
laboratory testing, 21
liver function tests (LFTs), 24
National Institute for Clinical
Excellence, 22
practice advisories, 20
pregnancy testing, 24
safety, 21
surgery scheduling, 21, 22
risk classication
preoperative complications, 19
procedures, 18
social, obesity, and functional status
factors, 20
Crew resource management (CRM), 63,
219, 220
adverse events, 259
airplane cockpit, 258
anesthesia induction phase, 260–262
complications, 251
human factors and resilience
adverse events, 257
airplane cockpit, 257
air trafc accidents, 257
decision-making process, 257
goal, 255
healthcare professionals, 256
HFE, 256
principles, 256, 258
procedure phase, 263
safe anesthesiologist, 253, 254
safe operating rooms, 252, 254, 255
safe stafng, 264–266
safe surgeon, 252, 253
sterile cockpit, 258–260
strategies, 264
Crisis resource management (CRM), 223,
224, 240
Critical administration threshold (CAT),
183, 184
Critical event practice, 232, 233
Critical incident stress debrieng (CISB), 238
Crossing the Quality Chasm, 201
D
Damage control resuscitation, 179
daVinci skills simulator (dVSS), 225
Debrieng Assessment for Simulation in
Healthcare (DASH) program, 240
Debrieng methods, 238–240
Deep vein thrombosis (DVT), 271
see also Venous thromboembolism (VTE)
De-nitrogenation, 304
Detection and reporting systems
GTT, 204, 205
mortality and morbidity, 202
NSQIP
AIMS, 207
SCIP, 206, 207
Veterans Affairs, 205, 206
Vizient, 206
PSIs, 203, 204
Difcult airway cart (DAC), 298
Difcult airway management (DAM)
airway catastrophes and hypoxia, 295
CICV, 309, 310
clinical practices, 296
complexity factors, 296
composite failure, 296
distal airway obstruction, 301
DMV
aspiration, 302
expected, 304
incidence, 305, 306
LMA, 306
unexpected, 305
video laryngoscope, 306
DTI
expected, 302, 303
incidence, 305, 306
LMA, 306
unexpected, 304, 305
video laryngoscope, 306
emergency conditions, 296, 297
equipment conditions, 298
ESA, 308–310
failure progression, 307
IMV, 308
laryngeal tube, 308
LMA, 308
mask ventilation, 302
NDMR and light anesthesia, 300
obstructive sleep apnea, 296
operator conditions, 297
opioids, 299
patient conditions
head position, 298
obesity, 298, 299
trauma, 299
prediction, 302
recovery time, 307
succinylcholine-induced Masseter
spasm, 300
upper airway obstruction, 300, 301
410
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Index
Difcult mask ventilation (DMV), 297, 301, 302
aspiration, 302
expected, 304
incidence, 305, 306
LMA, 306
unexpected, 305
video laryngoscope, 306
Difcult tracheal intubation (DTI)
expected, 302, 303
incidence, 305, 306
LMA, 306
unexpected, 304, 305
video laryngoscope, 306
Disruptive behavior
American Medical Association, 315
individual level, 321, 322
learner, 318, 319
manifestations, 316
perioperative safety and patient, 319, 320
prevalence, 315
situational stressors, 316
surgeon and staff, 317, 318
systems level, 322, 323
team level, 322
upstream and downstream effects, 316, 317
Distal airway obstruction, 301
Dolutegravir, 350
Donor–recipient crossmatching process, 175
E
Electromagnetic interference (EMI)
clinical response, 124
denition, 124
ESU, 124, 125
surgical equipment, 125
Electronic crossmatch, 175
Electrosurgical units (ESU), 124, 125,
331, 332
Emergency medical teams (EMTs), 381
Emergency surgical airway (ESA), 308, 309
Enhanced recovery after surgery (ERAS)
efciency, 279, 280
length of stay, 277, 278
nutrition and early feeding
antimicrobial prophylaxis and SSI
prevention, 285
carbohydrate, 282
early ambulation, 286
goal-directed uid therapy, 283, 284
intravenous uid replacement, 283
maintenance, 282
measurement, 282
opiate-sparing analgesia, 284, 285
VTE, 285
opioids
discharge prescriptions, 286, 287
epidemiology, 286
outpatient opioids, 287, 288
surgical procedures, 286
patient evaluation, education, and
engagement, 280, 281
safety, 278, 279
Environment delity, 217
Environmental Protection Agency (EPA), 144
Equipment delity, 217
Error of commission, 5
Error of omission, 6
Exposed employee (EE), 352
Exposure incident, 340
F
Failure mode and effect analysis (FMEA),
241, 242
Fires
education, 333–336
extinguishers, 333
re triad, 220, 221
fuels, 329
ignition source, 329
oxidizer, 328
risk assessment
fuels, 332, 333
ignition source, 331, 332
prevention, 330, 331
Silverstein Fire Risk Assessment, 329
Forcing functions, 10
Fresh frozen plasma (FFP), 179, 184
Fundamental Use of Surgical EnergyTM
(FUSE) program, 222
Fundamentals of endoscopic surgery (FES), 225
Fundamentals of laparoscopic surgery
(FLS), 225
G
General anesthesia (GA), 71
Global Trigger Tool (GTT), 204, 205
Goal-directed uid therapy (GDFT), 283, 284
Gossypiboma, 358
Graduated compression stockings (GCS), 110
H
Hawthorne Effect, 137
Healthcare Cost and Utilization Project
(HCUP), 203
Healthcare failure mode and effect analysis
(HFMEA), 11
Index
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411
Healthcare regulation, 244
Healthcare workers (HCW), 339, 344,
348, 349
Health Insurance Portability and
Accountability Act (HIPAA)
privacy rules, 343
Health Resources Availability Monitoring
System (HERAM), 381
Heart Rhythm Society (HRS), 126
Heparin-induced thrombocytopenia
(HIT), 115
Hepatitis B immunoglobulin (HBIG), 346
Hepatitis B vaccine (HBV)
follow-up counseling and testing, 347
PEP, 346, 347
risk assessment and management, 345, 346
risk of transmission, 341
Hepatitis C vaccine (HCV)
follow-up counseling, 348
risk assessment and management, 347, 348
risk of transmission, 341, 342
Hospital-acquired infections (HAI), 384
Human factors analysis
checklists, 9, 10
communication, 10
forcing functions, 10
just culture, 7, 8
patient history, 4
prospective and retrospective error
analysis, 11
RCA, 11–13
reporting system, 8, 9
rules, policies/procedures, 9
standardization, 9
Swiss cheese model, 4–7
Human factors engineering (HFE), 256
Human immunodeciency virus (HIV),
170, 339
counseling and education, 352
patient follow-up and monitoring, 351, 352
PEP
antiretroviral therapy regimens,
350, 351
indication, 349
populations, 351
timing and duration, 349, 350
window of opportunity, 349
psychological counseling and stress
management, 352
risk assessment and management, 348, 349
risk of transmission, 342
Hyperkalemia, 178
Hypocalcemia, 178
Hypomagnesemia, 178
Hypothermia, 177
I
Implantable cardioverter debrillator (ICD),
125, 126, 128
Implantable loop recorder (ILR), 125
Improving Surgical Care and Recovery
(ISCR), 400, 401
Institute for Healthcare Improvement (IHI), 204
Institute for Safe Medication Practice
(ISMP), 51
Institute of Medicine, 29
Intermittent pneumatic compression (IPC),
110, 111
International Classication of Diseases, Ninth
Revision, Clinical Modication
(ICD-9-CM), 203, 204
International Medication Safety Network
(IMSN), 55
Intraoperative adverse events (iAEs)
clinical assessment, 209
occurrence, 209
Surgical Apgar Score, 210
surgical scheme, 210–212
Invasive mechanical ventilation (IMV), 306, 308
J
Joint Commission, 30
Joint Commission International (JCI), 156
Just culture, 61
L
Laryngeal mask airway (LMA), 306, 308
Laryngeal tube (LT), 308
Low- and middle-income countries (LMICs),
372–379, 387, 388, 390
Low-dose unfractionated heparin (LDUH),
111, 112
Low molecular weight heparin (LMWH), 72,
77, 111, 112
Low ventricular ejection fraction (LVEF), 80
M
Mandibular protrusion test, 304
Mask ventilation (MV), 297, 300, 302
Massive transfusion protocols (MTP)
CAT, 183, 184
non-massive transfusion, 185
non-trauma patients, 185
over-transfusion, 183
prediction, 184, 185
resuscitation intensity, 183, 184
survival benet, 185
survival rates, 183
412
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Index
Mechanical interference, 125
Medication error (ME)
checklists, 52, 53
limiting verbal orders, 52
medication reconciliation, 52
medication shortage, 53, 54
perioperative setting
operating room quality and
safety, 51, 52
prevalence, 50, 51
standardization
culture, 61–64
drug trays and storage, 57, 58
labeling, 55–57
pharmacy, 59–61
technology solutions, 58, 59
Medication reconciliation, 52
Medication safety, 52
Metabolic alkalosis, 178
Methicillin-resistant S. aureus (MRSA), 89, 93
Military application of tranexamic acid in
trauma emergency resuscitation
(MATTERs), 186
Morbidity and mortality (M & M)
conference, 202
abdominal binder, 271, 272
ACS-NSQIP, 272
complications, 270, 271
feedback-and-review format, 270
history, 270
implementation, 271
leadership, 272
NQF, 272, 273
peer review privilege, 270
quality improvement, 272
voluntary reporting systems, 274
Myocardial infarction (MI), 78
N
National Quality Forum (NQF), 272, 273
National Surgical Quality Improvement
Program (NSQIP)
AIMS, 207
SCIP, 206, 207
Veterans Affairs, 205, 206
Vizient, 206
Needlestick Safety and Prevention Act, 353
Never events concept
care improvement, 30, 32
checklists
implementation challenges, 42–45
implementation history, 42
origins, 39–41
SURgical PAtient Safety System
(SURPASS) checklist, 38
CMS nonpayment policy, 32
Joint Commission, 30
NQF-dened events, 30, 31
patient safety, 30
preventable medical errors, 32
quality-improvement initiatives, 32
skin marking
hospital/facility standard, 38
Joint Commission, 37
patient involvement, 37
pre-induction/preoperative area, 38
Universal Protocol, 37
timeouts and debriengs
critical components, 36
environment safety, 34
implementation, 36
operating room staff, 34, 35
overview, 33
priority, 35, 36
routine and expected aspect of, 34
speaking/contributing
information, 35
Non-depolarizing muscle relaxation
(NDMR), 300
Non-narcotic adjuncts, 284
O
Obesity, 298, 299
Occupational exposure, 340
HBV
follow-up counseling and testing, 347
PEP, 346, 347
risk assessment and management,
345, 346
risk of transmission, 341
HCV
follow-up counseling, 348
risk assessment and management,
347, 348
risk of transmission, 341, 342
HIV
counseling and education, 352
patient follow-up and monitoring,
351, 352
PEP, 349–351
psychological counseling and stress
management, 352
risk assessment and management,
348, 349
risk of transmission, 342
risk of acquisition, 341
Index
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413
Occupational Safety and Health
Administration (OSHA), 339
Operating room (OR)
attire
gloves, 140
headgear, 140–142
personal belongings, 142
scrubs and jackets, 138–140
surgical masks, 138
checklists, 52, 53
distractions
communication failures, 142
disruptive behavior, 144, 145
noise sources, 143, 144
personal electronic devices, 143
re safety, 220–223
medication reconciliation, 52
quality and safety, 51, 52
surgical suite
restricted areas, 134, 135
semi-restricted areas, 134
unrestricted areas, 134
ventilation, 135
trafc
door openings, 135, 136
foot trafc control, 137
ventilation, 90
Opiate-sparing analgesia, 284–286
Opioids, 299
Oxygen-rich environment, 330, 331
P
Pacemaker (PM), 124–126
Patient blood management (PBM) programs,
187, 188
Patient-controlled analgesia (PCA) pumps, 58
Patient safety
culture, 235–238
limitation, 372
LMICs, 372
in perioperative care, 384–386
quality perioperative care
anesthesia safety, 377, 378
in childbirth, 381, 382
global stage, 389–391
Humanitarian Emergencies, 380, 381
infection control, 382, 383
pain management, 383, 384
surgical checklist, 378
trauma checklist, 379, 380
UHC
delivering quality perioperative
care, 375–377
global situation, 373–375
strengthening health systems, 387–389
surgical conditions, 373
WHO, 373
Patient Safety Indicators (PSIs), 203, 204
Pediatric advanced life support (PALS), 232
Pennsylvania Patient Safety Reporting System
(PA-PSRS) database, 50
Percutaneous coronary intervention (PCI), 74–76
Perioperative mortality rate (POMR), 373
Pharmaceutical services
clinical pharmacists, 60, 61
clinical pharmacy services, 60
drug preparation, 59
medication distribution system, 60
Plan, do, study, act (PDSA) cycle, 13
Post-exposure prophylaxis (PEP), 346, 347
antiretroviral therapy regimens, 350, 351
indication, 349
populations, 351
timing and duration, 349, 350
window of opportunity, 349
Post-traumatic stress disorder (PTSD), 352
Prehabilitation program, 281
Preventative periodic maintenance
(PPM), 252
Prospective, observational, multicenter, major
trauma transfusion (PROMMTT)
study, 180
Psychological delity, 217
PubMed, 399
Pulmonary emboli (PE), see Venous
thromboembolism (VTE)
Q
Quality improvement (QI), 87, 89, 379
R
Radio-frequency detection systems
(RFDS), 365–367
Radiofrequency identication (RFID)
technology, 60
Reason, James, 4–7
Regional anesthesia (RA), 285
anticoagulants and antiplatelet
medications
hemostasis-altering drugs, 72–74
postoperative outcomes, 71, 72
spinal hematoma, 70, 71
anti-hypertensive medications
ACEi and ARB, 80–82
beta blockers, 78–80
414
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Index
Regional anesthesia (RA) (cont.)
non-cardiac surgery
chronic anticoagulation therapy, 76–78
dual antiplatelet therapy, 75–77
Resident and Associate Society of the
American College of Surgeons
(RAS-ACS), 402
Resident education, 402, 403
Resident pathogens, 7
Resuscitation intensity (RI), 183
Retained surgical items (RSIs)
complications, 357
denition, 357
epidemiology, 358, 359
manual surgical counting
AORN, 361, 362
count discrepancies, 362, 363
human consistency and accuracy, 362
human error, 361
natural history, 359, 360
observational studies, 361
radiographs
bar-coded sponges, 364, 365
cost-effective analysis, 364
guidelines, 363
high-risk procedures, 364
intraoperative radiographs and variable
appearance, 363
RFDS, 365–367
sponges and instruments, 363
technological adjuncts, 364
risk factors, 360, 361
terminology, 358
Return to intended oncologic therapy
(RIOT), 279
Reversed WHO Pain Management Ladder, 383
Revised cardiac risk index (RCRI), 79
Root cause analysis (RCA), 11–13, 241
S
Safe Label System, 59
Safe operating rooms (SOR), 252
Safe Surgery Save Lives program, 52
Safety Attitudes Questionnaire (SAQ), 42
Safety culture
aviation industry, 61
denition, 61
domains, 61
effective process improvement, 64
high-reliability organizations, 62, 63
improvement, 61
organizational leadership and
commitment, 63, 64
surveys, 61, 62
Safety protocols, 381
Saudi Patient Safety Center (SPSC), 262, 265
Self-awareness, 321
Sequential gradient pneumatic leg
compression (SCD), 116
Serious reportable events, see Never
events concept
Service Availability and Readiness Assessment
(SARA), 389
Silverstein Fire Risk Assessment Tool, 329
SimSTAT, 240
Simulation
APSF, 230
cognitive aids, 233–235
communication, 232
critical event practice, 232, 233
debrieng, 238–240
development, 217
environment, equipment, and
psychological delity, 217, 218
high-risk elds, 230
infection prevention and control, 223
neurosurgery, 231
non-technical skills, 218
nursing education and interdisciplinary
team training, 231
obstetric machines, 230
operating room crisis resource
management, 223, 224
operating room re safety, 220–223
patient safety culture, 235–238
perioperative care
assessment, 241
crisis resource management, 240
current status, 244, 245
FMEA, 241, 242
healthcare regulation, 244
implementation, 243, 244
measurement, 242, 243
RCA, 241, 242
reenactment, 242
SimSTAT, 240
teamwork, 240
technical skills, 241
plastic surgery, 231
team-based competency
CRM, 219, 220
full-mission simulation, 220
quality, 219
self-assessments, 219
TeamSTEPPS™, 219
teamwork, 218
video assessment, 220
Index
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415
teamwork, 232
technical skills, 218, 224, 225, 233
Situation analysis tool (SAT), 388
Skill-based error, 5, 6
Sleep disordered breathing (SDB), 298, 299
Smart infusion pumps, 58
Society for Simulation in Healthcare (SSH),
244, 245
Spinal hematoma, 70, 71
Sterile cockpit, 258–260
Strengthening health systems, 387
Stress, 319
Succinylcholine-induced Masseter spasm, 300
Surgical Apgar Score, 210
Surgical Care Improvement Project (SCIP),
206, 207, 285
Surgical Council on Resident Education
(SCORE), 402
Surgical site infections (SSIs)
air exchange, 135
classication, 87, 88
denition, 87
foot trafc, 137
gloves, 140
hospital interventions, 93–95
adhesive incise drapes, 98
antibiotic sutures, 98
euvolemia, 97
gloves/instruments, 98
hair removal, 96
incisional wound irrigation, 98
normothermia, 97
operating room ventilation, 99
perioperative glucose control, 95, 96
perioperative supplemental
oxygenation, 97
preoperative skin preparation, 96
prophylactic antibiotics, 96, 97
surgical attire, 96
surgical hand scrub, 96
wound care, 99
wound protector, 98
LAF ventilation system, 136
microbiology, 89, 90
post-hospital interventions, 99
prehospital interventions, 91, 92
bowel preparation, 93
glucose control, 93
MRSA screening, 93
preoperative bathing, 92
smoking cessation, 92
prevention, 285
rates, 136
risk factors, 90, 91
surgical mask, 138
Surgical specimen handling
clinical history, 159, 160
communication between clinicians and
pathologists, 157, 158
interventions, 164, 165
intraoperative consultation, 163, 164
patient identication, 156, 157
tissue identication and orientation, 160
tissue preservation, 161–163
tissue transportation, 163
Surgical Teamworking in Emergency and
Acute Medical Situations
(S-TEAMS), 219
Sustainable Development Goals (SDGs), 373,
387, 389
Swiss cheese model, 4–7
T
Teach back technique, 386
Team-based competency
CRM, 219, 220
full-mission simulation, 220
quality, 219
self-assessments, 219
TeamSTEPPS™, 219
teamwork, 218
video assessment, 220
Team Strategies and Tools to Enhance
Performance and Patient Safety
(TeamSTEPPS™), 219, 322, 401
Team-training programs, 322
Technical skills training, 224, 225
Tenerife airport disaster, 256
Thoracic epidural anesthesia (TEA), 284
“To Err is Human" report, 201, 320
Tracheal tube, 335, 336
Tranexamic acid (TXA), 186, 187
Transfusion-associated circulatory overload
(TACO), 174
Transfusion-related acute lung injury
(TRALI), 174
Transfusion-related immunomodulation
(TRIM), 174
Transfusion-transmitted infections (TTIs),
170, 171
2013 Accreditation Council for Graduate
Medical Education (ACGME), 52
U
Undifferentiated carcinoma, 159
Unfractionated heparin (UFH), 77
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