Pierce lecturer addresses challenges to patient safety in developing world


Alexander A. Hannenberg, M.D., discussed challenges in patient safety around the world when he presented the Ellison C. Pierce, Jr., Memorial Lecture Saturday.

In his Ellison C. Pierce, Jr., Memorial Lecture Saturday, Alexander A. Hannenberg, M.D., provided a comprehensive look at the patient safety challenges facing developing nations in surgery and the administration of anesthesia, saying that about 5 billion people in developing countries lack access to surgical care and 7 million die or become disabled from surgical complications.

Dr. Hannenberg is Clinical Professor of Anesthesiology at Tufts University School of Medicine in Boston, Associate Chair of Anesthesiology at Newton-Wellesley Hospital in Newton, Massachusetts, and a past president of ASA (2010).

Between 2004 and 2012, global access to surgery underwent a dramatic 33 percent increase, he said. “Surgery has now become a more frequent event worldwide than childbirth. The troubling question is whether the growth we have witnessed and the improvement in access that we see will lead to a proportional increase in the numbers killed or disabled.”

Linking improved access to improved safety is “an absolute imperative,” Dr. Hannenberg stressed. “We can do much better than by proliferating unsafe surgery.”

Studies from Africa in countries that have limited health care systems indicate that avoidable mortality is 100 times to 1,000 times greater than in developed countries, he said. Consequently, many people in countries such Malawi may fear surgery more than a lifetime of pain and disability.

The Human Development Index is a tool used to quantify disparities in surgical anesthetic outcomes published since 1990 by the United Nations Development Program. In 2014, the index showed the extremes in mortality related to anesthesia, with Norway having the lowest mortality and Niger the highest.

A number of risk factors are associated with surgery-related mortality, Dr. Hannenberg said. “There is significant and tragic excess risk with surgery in low-resource settings and much of that risk is rooted in unsafe anesthesia.”

The drivers of that risk include inadequate teamwork and communication among surgical team members, an inadequately trained workforce and inadequate material resources.

The World Health Organization’s surgical safety checklist can be used to facilitate teamwork and communication among the surgical staff, he said.

“The checklist demands several conversations among all members of the surgical team. Forcing these discussions into routine practice will not only catch errors and omissions but also increase the likelihood of effective collaboration when faults in the perioperative process actually do occur,” he commented.

While 80 percent of medical equipment used in developing countries is donated, no more than 30 percent of that equipment can be put into service, he said. The World Health Organization warns that there should be no double standard in the quality of the donated equipment. If the quality of an item is unacceptable in the donor country, it is also unacceptable as a donation.

Dr. Hannenberg concluded by saying that promoting greater access to surgery demands a commitment to greater patient safety. “The gap in access to surgery causes suffering and death, but preventable harm from surgery is also a huge tragedy.”

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