Acessibilidade / Reportar erro

Patient safety in plastic surgery: a systematic review

ABSTRACT

Introduction:

patient safety has become an increasingly present topic in health research. Plastic surgery is a specialty in evidence, and it is necessary to adapt patient safety to its particularities.

Methods:

Systematic review to investigate actions related to patient safety in plastic surgery. MEDLINE and SCIELO were chosen to locate the studies. The descriptors: “patient safety” and “plastic surgery” were used in the MEDLINE database. In SCIELO, the descriptors: “segurança do paciente” e “cirurgia plástica” were used. In both cases, the publication period was between 2012-2018, totaling 15 articles.

Results:

The countries that published the most on the subject were the United States and Brazil. The most frequent concern was safety related to the training of plastic surgery residents. Tools like the checklist have also been used to improve security. Another concern that requires more study will be if the weekends have higher complications with surgeries performed during the week. However, well-formulated medical records, as well as the Informed Consent Form (ICT), appear to have a more solid basis in patient safety. Pre-anesthetic consultation also seems to favor patient safety. Furthermore, finally, the use of WhatsApp seems to be a safe tool, and that improves the care provided by the medical team.

Conclusion:

The need for more in-depth studies on this topic is emphasized, considering that a systematized protocol was not found.

Keywords:
Patient safety; Plastic surgery; Systematic review; Research on health services; Health policy

RESUMO

Introdução:

A segurança do paciente tem se tornado um tema cada vez mais presente nas pesquisas na área da saúde. A cirurgia plástica é uma especialidade em evidência e torna-se necessário adequar a segurança do paciente as suas particularidades.

Métodos:

Revisão sistemática com a finalidade de investigar as ações relacionadas à segurança do paciente em cirurgia plástica. Para localizar os estudos foram escolhidas a MEDLINE e SCIELO. Na Base de dados MEDLINE foram usados os descritores: “patient safety” and “plastic surgery”. Na SCIELO foram usados os descritores: “segurança do paciente” e “cirurgia plástica”. Em ambos os casos o período das publicações foi entre 2012-2018, somando um total de 15 artigos.

Resultados:

Os países que mais publicaram sobre o assunto foram os Estados Unidos e o Brasil. A preocupação mais frequentemente encontrada foi a segurança relacionada à formação do residente de cirurgia plástica. Também ferramentas como o checklist têm sido usadas para a melhoria da segurança. Outra preocupação que exige mais estudos seria se os finais de semana apresentam maiores complicações em relação às cirurgias realizadas durante a semana. Porém, parece ter fundamentos mais sólidos na segurança do paciente o prontuário médico bem formulado, assim como o termo de consentimento informado (TCI). A consulta pré-anestésica também parece favorecer a segurança do paciente. E, por fim, o uso do WhatsApp que parece ser uma ferramenta segura e que incrementa o atendimento da equipe médica.

Conclusão:

Ressalta-se a necessidade de estudos mais aprofundados sobre esta temática, considerando-se que nenhum protocolo sistematizado foi encontrado.

Descritores:
Segurança do paciente; Cirurgia plástica; Revisão sistemática; Pesquisa sobre serviços de saúde; Política de saúde

INTRODUÇÃO

Patient safety has become an increasingly present topic in health research, which worries researchers around the world11 Reis CT, Martins M, Laguardia J. A segurança do paciente como dimensão da qualidade do cuidado de saúde: um olhar sobre a literatura TT. Ciênc Saúde Coletiva. 2013;18(7):2029-36..

Concomitantly, the demand for plastic surgery has become more and more frequent due to the advent of new technologies and social acceptance. Culturally, plastic surgery is considered a safe procedure for the patient, however it is emphasized that there are associated risks as in any other surgical procedure22 Saldanha OR, Salles AG, Ilaverias F, Saldanha Filho OR, Saldanha CB. Fatores preditivos de complicações em procedimentos da cirurgia plástica sugestão de escore de segurança. Rev Bras Cir Plást. 2014;29(1):105-13..

We need to use History to discuss this topic, from Hippocrates, with the famous phrase “Primun non nocere,” to Florence Nightingale, an English nurse, who in the 19th century, when working in the Crimean War, advocated quality care for wounded soldiers.

A global landmark on the subject was the report “To err is human: building a safer health system,” which brought up the debate on deaths due to health errors in the United States.

In Brazil, the bedside book was written by Souza and Mendes, in 201433 Souza P, Mendes W. Segurança do paciente. Rio de Janeiro: Fiocruz; 2014., authors who studied the subject and that demonstrate the specific conceptual aspects of the subject area and also a historical and legal contextualization on safety and quality in health services.

The World Health Organization (WHO) launched, in 200444 World Health Organization (WHO). Summary of the evidence on patient safety: implications for research. Geneva: WHO; 2008., the World Alliance for Patient Safety, with the purpose of awakening the commitment among health professionals to improve the safety of patient care, being the surgical environment a first place to implement security practices55 World Health Organization (WHO). World alliance for patient safety. Implementation manual surgical safety checklist. Safe Surgery saves lives. Geneva: WHO; 2008..

In 2011, the International Joint Commission (IJC) launched the six International Goals for Patient Safety (IGPS), which are: 1 - correct patient identification; 2 - good hand hygiene practices; 3 - effective communication; 4 - safe surgery; 5 - safety in the prescription, dispensing, administration/use of medications, diets and blood components; 6 - prevention of falls and pressure injuries.

Sequentially, the National Patient Safety Program (PNSP), instituted by the Ministry of Health (MS), was launched in 201366 Monteiro F, Silva LR. "Checklist" lista de verificação de segurança cirúrgica: avaliação e intervenção. Rev Ciênc Méd Biol. 2013;12(4):482-5., which aims to incorporate assistance, educational and programmatic actions in the context of medical care, to reduce the number of adverse events that can lead to any type of harm to the patient. These actions include the implementation of Patient Safety Centers in health facilities, which include risk management and monitoring of patient safety77 Ministério da Saúde (BR). Agência Nacional de Vigilância Sanitária. Segurança do paciente e qualidade em serviços de saúde: uma reflexão teórica aplicada à prática. Brasília (DF): Ministério da Saúde; 2013..

In this sense, in relation to the surgical patient, concern has increased due to the high incidence of errors and adverse events, which in approximately 50% of cases could have been avoided88 Ferraz EM. A cirurgia segura: uma exigência do século XXI. Rev Col Bras Cir. 2009;39(4):281-2..

Regarding patient safety, it is recurrent in the literature that there are several benefits in the implementation of preventive measures against adverse events in the operating room, among which the application of safety checklists in surgery stands out, due to their effectiveness in the reduction of preventable surgical complications, infections and, consequently, mortality99 Alpendre FT, Cruz E, Dyniewicz AM, Mantovani MF, Silva AE, Santos GS. Safe surgery: validation of pre and postoperative checklists. Rev Latino- Am Enfermagem. 2017;25:e2907..

The surgical safety checklist (SSC) is part of the actions proposed by the Ministry of Health, in the Safe Surgery Program saves lives, and should be applied before anesthetic induction and surgical incision and at the end of the procedure, before the patient leaving the operating room1010 World Health Organization (WHO). WHO guidelines for safe surgery: safe surgery saves lives. Geneva: WHO; 2009..

Carrying out studies on the safety of the surgical patient and the implementation of preventive measures are extremely positive actions, with a relevant impact factor, since according to the WHO recommendations there are three ways to achieve patient safety: prevention of adverse events, the discussion of adverse events that occurred, making them visible and minimizing their effects through assertive interventions44 World Health Organization (WHO). Summary of the evidence on patient safety: implications for research. Geneva: WHO; 2008..

Given this scenario, there are attempts made to identify in the literature protocols, activities, and programs related to patient safety in plastic surgery, to investigate actions related to patient safety in plastic surgery.

METHODS

It is a systematic review of the literature, a research designed to be methodical, explicit and reproducible, which requires the elaboration of a clear research question, definition of the search strategy and inclusion and exclusion criteria, and a thorough data analysis1111 Sampaio RF, Mancini MC. Estudos de revisão sistemática: um guia para síntese criteriosa da evidência científica. Rev Bras Fisioter. 2007;11(1):83-9..

In this sense, the terms “patient safety” and “plastic surgery” were investigated in the Cochrane Library using the fields: Title, Abstract, Keywords, and All fields. Three systematic reviews were found, namely: 1 - “Perioperative corticosteroids for preventing complications following facial plastic surgery,” whose objective is to determine the effects of perioperative administration of corticosteroids; 2 - “Wound drainage after plastic and reconstructive surgery of the breast” the objective of which is to compare the safety and efficacy of the use of wound drains after elective plastic procedures and reconstructive breast surgery; 3 - “Surgical orbital decompression for thyroid eye disease,” to review the current published evidence on the efficacy of surgical orbital decompression for disfiguring proptosis in adult thyroid eye disease and summary information on possible complications and quality of identified studies. Therefore, the reviews sent to Cochrane have, in fact, objectives that are diametrically opposed to the purpose of this review.

Next, the researchers analyzed the 27 elements of PRISMA (Preferred Reporting Elements for Systematic Review and Meta-analysis Statement) to verify the essential parts of a systematic review.

To answer the research question, the researchers searched the databases for descriptors: “segurança do paciente”, “cirurgia plástica” e “protocolos”. Although it was investigated in different bases, the result was null, that is, in no base were articles found on this topic. Finally, after reflections, the PVO was established as follows:

  • P: patient safety;

  • V: patient safety in plastic surgery;

  • O: actions related to patient safety in plastic surgery.

To locate the studies, the databases chosen were MEDLINE and SCIELO.

The following keywords were used in the MEDLINE database: “patient safety” and “plastic surgery,” found in the title and abstract, and the following filters were applied: language: Portuguese, English and Spanish, text full and publication period between 2012-2018, using the primary Mesh.

In SCIELO, the descriptors: “patient safety” and “plastic surgery” were used in all the indices, and the following filters were applied: language - Portuguese, English and Spanish, thematic area of health sciences, full text available and Publication period between 2012-2018.

Regarding the search results, in MEDLINE, there were a total of 55 articles initially, of these, 33 were excluded because they did not meet the research objectives, two were excluded for not meeting the language filter, 1 in Swedish and 1 in German, and 2 for being repeated. After this first analysis, for the critical evaluation of the studies, four articles were excluded, since during the in-depth reading it was observed that there was no adherence to the question and the research objectives, three were eliminated because they presented low evidence ( level of evidence 3 and 4) indicated by the author of the articles and the magazine, a total of 11 articles from this database to compose the sample.

In SCIELO, there were a total of 11 articles in the initial search, of which one was excluded because it was a case study, and six were excluded after reading titles and abstracts, without meeting the research question and objectives, totaling four articles from this database to compose the sample.

There were 15 articles left to compose the final sample after adding the search results from the two databases, as shown in Figures 1 and 2.

Figure 1
Flowchart for the selection of MEDLINE articles.

Figure 2
Flowchart for the selection of SCIELO articles.

RESULTS

For analysis of the sample of this study, the following tables were constructed (Tables 1 to 4).

Chart 1
Title, authors and year of selected articles.
Chart 2
Objectives and country of the selected articles.
Chart 3
Research method and participants of the selected articles.
Chart 4
Results and Conclusions of the selected articles.

DISCUSSION

The studies that integrated the sample of this systematic review show that in 2016 there were four publications, with the largest number, followed by the years 2015 and 2012, with three publications on the subject studied, the rest published one article per year. The most prevalent countries found in the production of works on patient safety in plastic surgery were the United States and Brazil, with about 46% of the works being American and 33% of Brazilian works, 13% are from German authors, and 6.6 % are English.

As for the types of studies carried out, 26.5% of them were intervention research, 20.1% cohort, 20.1% retrospective, 13.3% analytical study, 13.3% retrospective correlational, and 6.7% transversal series.

The study participants were mostly patients with 41%; health professionals accounted for 18% of the participants; 12% were residents, and 6% a more specific population, pediatric patients.

After presenting the overview of the selected articles, for the best didactic effect, the content of the articles in the sample was divided into three categories, namely:

  1. Preoperative period;

  2. Transoperative period;

  3. Perioperative period.

Preoperative period category

Surgery always begins with the patient in the office when the benefits and risks of the procedure to be performed are explained. In this sense, it is necessary to use the term of informed consent (ICT). Doncatto, in 20121212 Doncatto LF. Uso do termo de consentimento informado em cirurgia plástica estética. Rev Bras Cir Plást. 2012;27(3):353-8., performed a retrospective analysis on 100 judgments of the Courts of Justice of 5 Brazilian states, from July 2010 to August 2012, in cases related to cosmetic plastic surgery, excluding cases of restorative plastic surgery. The last 20 trials of each state were considered, covering a total of approximately 3,427 active plastic surgeons, where the most frequent causes of the actions and the main evidentiary elements that led to the conviction or acquittal of the cases were evaluated. The author noted that in cases of medical process, in addition to a favorable expert opinion, the appropriate use of the consent form was the most relevant aspect in cases in which there was absolution.

Therefore, the Informed Consent Form represents safety for the plastic surgeon and the patient, since it equals and consolidates the relationship of trust and transparency between the two, fulfilling the obligation of the doctor to inform the patient and in turn that this patient declares that understood and that he/she agrees to submit to the proposed treatment, allowing the doctor legal certainty, unless the term has been obtained irregularly.

Many lawyers have considered plastic surgery to be a result-binding specialty. Therefore, there is a condemnation without any malpractice, imprudence or negligence, disregarding the biological, technical and specific aspects of the patient. Doncatto, in 201212, (p. 353) still notes that:

“Brazilian judges are increasingly adopting a new jurisprudence, in line with a contemporary trend and following in the footsteps of the French and Canadian trends, which consider cosmetic plastic surgery as best-endeavors contract, therefore, require testing the guilt of the doctor to condemn him. “

The required result obligation of cosmetic plastic surgery has generated uneasiness in the medical profession, as many judges have not yet understood that it is impossible to guarantee results in all types of surgery, as organic tissues react differently to the will of both the physician and the patient. In this perspective, the author considers that the consent form leaves the doctor-patient relationship in addition to being transparent, respectful in the sense of the patient’s autonomy for his body, aware of the advantages and disadvantages, risks, and possible results. He says: “in turn, the plastic surgeon, when using the ICT properly, demonstrates suitability, good intentions, good principles and honesty, a fact that becomes an attenuator1212 Doncatto LF. Uso do termo de consentimento informado em cirurgia plástica estética. Rev Bras Cir Plást. 2012;27(3):353-8..

The consent form must provide adequate and sufficient information, containing the nature and purpose of the treatment, the probable risks and benefits, the alternative treatments, in addition to the risks of failing to perform the proposed treatment or the alternatives. Doncatto, in 20121212 Doncatto LF. Uso do termo de consentimento informado em cirurgia plástica estética. Rev Bras Cir Plást. 2012;27(3):353-8., observed that in cases of medical process, in addition to a favorable expert opinion, the proper use of the consent form was the most relevant aspect in cases in which there was an acquittal.

The article called “Anesthetic complications in plastic surgery and the importance of pre-anesthetic consultation as a safety instrument” already points to the aspect of patient safety according to the pillars of the Federal Council of Medicine, which says it has been mandatory since 2006, the pre-anesthetic consultation (CFM, in 2016X). Schwartzman et al., In 20111313 Schwartzman UP, Batista KT, Duarte LTD, Teixeira D, Saraiva RA, Fernandes MC, et al. Complicações anestésicas em Cirurgia Plástica e a importância da consulta pré-anestésica como instrumento de segurança. Rev Bras Cir Plást. 2011;26(2):221-7., in a retrospective and analytical cohort study of hospital patients, discussed the anesthetic complications of surgical procedures in a given hospital in Brazilia. In the preoperative periods, pre-anesthetic consultations were carried out with clinical evaluation and description of the anesthetic plan.

The authors, in agreement with Doncatto, in 20121212 Doncatto LF. Uso do termo de consentimento informado em cirurgia plástica estética. Rev Bras Cir Plást. 2012;27(3):353-8., previously presented, also state that the informed consent form was signed, which is kept confidential, attached to the medical record. The focus of this study was the main information obtained in the pre-anesthetic consultation and the classification of the patient’s physical state.

As a result of this study, it was found that 6365 anesthetic procedures were performed between April 2006 and December 2007, and of these, 2.74% had an anesthesia-related complication rate. Several specialties have been researched, and concerning plastic surgery, even with complex procedures for reconstruction of the upper limb (neurotendinous lesions and tumors), lower limb, injuries to the trunk (pressure ulcers, myelomeningocele and ostemilielitis), there was a complication in 8%, compared to orthopedics, with 46.25% and neurosurgery with 24.6%. Regardless of surgical specialty, the authors identified hypotension with 22.8% of cases as an anesthesia-related complication, followed by vomiting and arrhythmias with 13.7% and perforation of the dura mater and laryngospasm with 6.3%.

Schwartzman et al., In 20111313 Schwartzman UP, Batista KT, Duarte LTD, Teixeira D, Saraiva RA, Fernandes MC, et al. Complicações anestésicas em Cirurgia Plástica e a importância da consulta pré-anestésica como instrumento de segurança. Rev Bras Cir Plást. 2011;26(2):221-7., point out that the team of health professionals, composed of anesthetists and nurses, is of paramount importance for the realization of pre-anesthetic consultation in the context of patient safety in plastic surgery, “as it can reduce complications intra and postoperative periods and avoid unfavorable outcomes ”(p. 226).

Also, in this category, we can point out the study by Rezaeian et al. in 20131414 Rezaeian F, Schantz JT, Sukhova I, Schenck TL, GIunta RE, Harder Y, et al. Training in aesthetic surgery at a university clinic - the Munich model. Handchir Mikrochir Plast Chir. 2013 Oct;45(6):370-5., a German publication, which sought to develop, implement and evaluate a new concept of teaching and training in aesthetic plastic surgeries. Although this research was carried out with residents, a fact that will be discussed in another category of analysis, the central point is the training program carried out in 304 aesthetic surgeries of body, breast and facial contour. The responsible physicians used these surgeries to teach residents the best techniques and recorded cases where complications occurred as an indicator of patient safety. It emerged from the study that training was effective, considering that the incidence of complications from educational surgeries and those that did not compose the research sample, that is, that were not for teaching the residents, had practically the same percentage of complications, being 4.4% for elective surgeries and 4.9% for educational ones.

Transoperative period category

For this category, some articles dealt with issues related to the transoperative period, such as a checklist, surgical evolution, iatrogeny, adverse events, and communication.

Prates et al., in 20181515 Prates CG, Stadñik CMB, BagatinI A, Caregnato RC, Moura GMSS. Comparação das taxas de infecção cirúrgica após implantação do checklist de segurança. Acta Paulista Enfermagem. 2018;31(2):116-22., demonstrate that the checklist can also be used to reduce rates of surgical infection. According to the authors, surgical infections are recognized worldwide as a serious public health problem because they are associated with high morbidity and mortality, increased length of stay, and hospital costs. They are one of the main targets of epidemiological surveillance in health institutions. In underdeveloped and developing countries, the authors claim that it can affect up to a third of patients undergoing surgical procedures. Monitoring and implementing effective strategies to prevent them in health facilities have been stimulated and driven by worldwide movements for patient safety. Surgical site infections are, for the authors, preventable adverse events and markers of low quality of care, requiring efforts by health professionals and institutions to reduce them.

Also related to the checklist, the study by Sucupira et al., In 20161616 Sucupira E, Matta R, Zuker P, Matta J, Arbeláez JP, UebeL CO. Aesthetic plastic surgery checklist: a safety tool. Aesthetic Plast Surg. 2016 Oct;40(5):785-91., describes authors who recall in their work “Aesthetic Plastic Surgery Checklist: A Safety Tool” that about 10% of patients have iatrogenic events and that more than half of them occur in the perioperative environment. The research aimed to develop a complete and functional checklist for cosmetic plastic surgery and to test it in patients undergoing elective plastic surgery. It was developed a complete checklist to improve patient safety in cosmetic plastic surgery.

Although the authors marked the level of evidence in this study as IV, the results point to the use of data from 486 patients, 430 of whom were female, and 56 of whom were male, with the most commonly performed liposuction in 305 cases and anesthesia plus sedation. As for complications, the authors identified seromas with 7%, other complications not related to the wound with 3%, and the group that most adhered to the use of the checklist was the group of residents.

In the paper, it was demonstrated that the use of the checklist allows the collection of data and the identification of potential risks, promoted favorable changes in the attitudes of some professionals, and generated interest in patient safety and the team labor.

Another article that is classified in the category related to the transoperatory period is the one that discusses the safety of the technique itself. Amorim et al., in 20121717 Amorim Filho HC, Amorim CCB. Lipoabdominoplastia no tratamento estético do abdome: experiência de 5 anos. Rev Bras Cir Plást. 2012;27(2):301-8., in their work on lipoabdominoplasty, demonstrates that surgical techniques undergo evolution over time, resulting in greater safety for the patient. The author demonstrates that the evolution of the technique has made lipoabdominoplasty a more elaborate surgery, enabling the achievement of good results by knowing the safety limits of the surgery.

A retrospective study was carried out using 162 medical records of patients who underwent lipoabdominoplasty over five years, and the results show a significant reduction in cutaneous-adipose tissue, with a significant decrease in abdominal flaccidity and an improvement in body contour.

The author reports that the safety of this procedure is modernly based on decreased detachment of the abdominal flap. On the other hand, it is undeniable the greater viability and safety of a less detached flap, which preserves its vascular and sensitive source. This safety for flap irrigation is described in studies with Doppler, as shown by the authors. That is, the lipoabdominoplasty technique is a safe procedure, with a low rate of complications, as long as the safety criteria described by the authors are respected. This proceeding allows obtaining a well-vascularized flap, with preservation of perforating arteries. Amorim et al., In 20121717 Amorim Filho HC, Amorim CCB. Lipoabdominoplastia no tratamento estético do abdome: experiência de 5 anos. Rev Bras Cir Plást. 2012;27(2):301-8., stated that the postoperative complications found in the medical record review are low and meet the incidences reported in the literature.

Hernandes-Boussard et al., In 20151818 Hernandez-Boussard T, McDonald KM, Rhoads KF, Curtin CM. Patient safety in plastic surgery: identifying areas for quality improvement efforts. Ann Plast Surg. 2015 May;74(5):597-602., remember that adverse events are not rare, 3.7% of all hospital admissions experience an adverse event, and most of these events are considered preventable. In addition to the impact on the patient and his family, adverse events increase the use of hospital resources and the costs of hospitalization.

Given the wide-ranging impact of these events, there has been global prioritization in patient safety and associated hospital performance. The authors say that plastic surgery is a surgical discipline with its particularities, that there are essentially two groups of patients who need reconstructive plastic surgery: elective patients, who are generally young and healthy adults; and, complex patients, who need reconstructive surgery due to other conditions, such as the closure of exposed wounds, reconstruction after tumor removal or injury repair such as burns. It was observed in their work that patients undergoing reconstructive plastic surgery, in general, had lower rates of complications than other surgical specialties, but adverse effects were not uncommon. Over five years, a total of 16,635 patients experienced at least one potentially preventable adverse event during hospitalization. These events led to more than twice the patient’s hospital stay time and increased hospital expenses.

Sidhoum et al., In 20161919 Sidhoum N, Dast S, Abdulshakoor A, Assaf N, Herlin C, Sinna R. WhatsApp: improvement tool for surgical team communication. J Plast Reconstr Aesthet Surg. 2016 Nov;69(11):1562-3., discuss, in their work, the relatively modern concern in patient safety that has been the use of social media such as Whatsapp. The author recalls that concerns such as the dissemination of data and images of patients that would be protected by medical confidentiality are considered, but the safety of this data in new media and mobile devices is questioned. Instant messaging can be used as a valuable tool to coordinate surgical teams or for simpler patient guidance. It is a valuable approach to simplify communication.

The authors present the experience and results of the plastic surgery team at Centro Hospitalar Universitário Amiens, using instant messaging as part of medical communication for almost three years. In terms of daily time spent writing messages, the statistics are quite favorable and show no detrimental time wasted with using WhatsApp. The use of this tool seems to keep the medical team in a continuous call throughout the day, favoring the treatment of patients. Regarding the technical characteristics involving security in 2014, the Electronic Frontier Foundation, an independent American institution that defends civil liberties in the world, assessed the vulnerability of WhatsApp messages to measure their security by a complex analysis of their encryption. This institution concluded that WhatsApp has a good level of security and confidentiality, guaranteeing the security of the data and communications exchanged. A disadvantage would be the medical record. Undeniably, medical information shared through WhatsApp during the patient’s hospitalization does not appear in his medical record. However, even so, instant messaging is an effective, inexpensive, and safe tool for professional communication. It does not seem to harm oral communication and brings better communication from the surgical team.

Tadisina et al., In 20152020 Tadisina KK, Chopra K, Singh DP. The "weekend effect" in plastic surgery: analyzing weekday versus weekend admissions in body contouring procedures from 2000 to 2010. Aesthet Surg J. 2015;35(8):995-8., raised another interesting question regarding patient safety in plastic surgery in the transoperative category. The authors question whether the procedures performed during the week would have any difference in terms of safety concerning those performed at the weekend. The authors point out that several studies demonstrate greater complications on weekends. This situation would be attributed to the lack of availability of personnel, services, and worse access to diagnostic tests. It can also be seen that the surgeon is without his usual team at the weekend. However, the authors remember that these studies do not take into account the particularities of plastic surgery patients, who are generally healthier. Even so, there are the factors mentioned that are independent of the health of the surgical patient, such as the decrease in hospital resources on weekends, including the team and access to diagnostic tests.

Besides, Tadisina et al., in 20152020 Tadisina KK, Chopra K, Singh DP. The "weekend effect" in plastic surgery: analyzing weekday versus weekend admissions in body contouring procedures from 2000 to 2010. Aesthet Surg J. 2015;35(8):995-8., reported that plastic surgeons often end up operating on weekends due to the lack of an operating room during the week, as these are used for emergency cases, which can result in more operative cases being performed on weekends. The authors were the first to investigate whether there is a relationship between patient safety and plastic surgery on weekends. They consider that although it seems to be negative, this subject needs further investigation.

Perioperative period category

This category was the one with the highest number of selected articles. It is believed that since many subjects are related to various times that involve surgery in its different aspects, this category covers most of the studies in this review.

It will begin with different investigations that inform the participation of residents in the surgical act, such as Koulaxouzidis et al. in 20142121 Koulaxouzidis G, Momeni A, Simunovic F, Lampert F, Bannasch H, Stark . GB. Aesthetic surgery performed by plastic surgery residents: an analysis of safety and patient satisfaction. Ann Plast Surg. 2014;73(6):696-700., in their work, they performed 273 aesthetic procedures in 206 patients. They demonstrated that cosmetic surgery performed by plastic surgery residents, under the supervision of medical assistants is safe and provides high levels of postoperative patient satisfaction. Furthermore, offering these services can bridge the gap between providing training in high-quality cosmetic plastic surgery and, at the same time, allowing an increasing number of patients who can perform procedures less cheaply.

Similarly, in the article “The Impact of Resident Participation in Outpatient Plastic Surgical Procedures,” Massenburg et al., in 20152222 Massenburg BB, Sanati-Mehrizy P, Jablonka EM, Taub PJ. The impact of resident participation in outpatient plastic surgical procedures. Aesthetic Plast Surg. 2015;40(4):584-91., observed all outpatient procedures performed by plastic surgeons between 2007 and 2012 in the database of the National Health Improvement Program American College of Surgeons Surgical Quality. The authors assessed the impact of residents’ participation in the surgery of 6,227 patients and the results demonstrate that initially, the resident’s presence may appear to increase the levels of complication, however, in conclusion, a more careful analysis shows that the levels of safety and complications are the same as those of more experienced surgeons. It is reiterated that this study has a level of evidence II.

Qureshi et al., in 20162323 Qureshi AA, Parikh RP, Myckatyn TM, Tenenbaum MM. Resident cosmetic clinic: practice patterns, safety, and outcomes at an academic plastic surgery institution. Aesthet Surg J. 2016 Oct;36(9):NP273-80., remember that plastic surgery procedures tend to be costly for patients. The authors, considering the American health care system, remember that services that have medical residency in general, imply less expensive procedures. They exemplify through patients that after bariatric surgery, they lose much weight. Health insurance only covers expenses for abdominal surgery, but these patients generally require other procedures such as brachioplasty or cruroplasty.

The authors report that surgery services where there is teaching, health institutions that are references in teaching, could enable these procedures to be performed with the same levels of complication and safety as clinics with trained surgeons at a lower cost to patients. In this study, the authors assessed the safety of procedures performed at a school clinic and statistically compared it with the results of national cosmetic surgery, concluding that in 175 cosmetic procedures, there was a general complication rate of 1.7%, compared with 2,0% for patients in the Cosmet Assure database.

When talking about event notification by residents, Parikh et al., 20172424 Parikh PR, Snyder-Warwick A, Naidoo S, Skolnick GB, Patel KB. Impact of an event reporting system on resident complication reporting in plastic surgery training: addressing an ACGME and Plastic Surgery Milestone Project Core Competency. Plast Reconstr Surg. 2017 Nov;140(5):736e-45e., demonstrated that an intervention using an online event notification system, developed by the head of the plastic surgery department, in conjunction with Patient safety experts have led to significant improvements in the reporting of complications by plastic surgery residents at an academic hospital.

The proportion of complications reported in the pre-intervention group of the notification system was 28.1%; after the intervention, this increased significantly to 91.4% (p <0.001). Therefore, the authors demonstrated that the implementation of this system could improve learning and safety in plastic surgery by improving reports of complications. Also, the authors point out that the involvement of residents in quality improvement initiatives is essential to train physicians for clinical practice in a complex health system.

Also, in this category, there is the issue of documentation that involves all surgical procedures. Within this context of medical documentation, Kittinger et al., 20162525 Kittinger BJ, Matejicka II A, Mahabir RC. Surgical precision in clinical documentation connects patient safety, quality of care, and reimbursement. Perspect Health Inf Manag. 2016 Jan;13:1., proposed a project to improve the quality and safety of care performed at the Plastic Surgery Division of Scott & White Memorial Hospital. The main focus of the project involved improving the clinical documentation of inpatients. This interaction between doctors and specialists, in documentation in the health area, allowed the doctors to write down in the medical record all the diagnoses relevant to the treatments that were provided during hospitalizations. The plastic surgery service was able to improve its documentation and, in doing so, improved the recognition of the complexity of the patients it was treating. It has been shown that an effort to improve documentation has proved fruitful in terms of quality of care and cost management for the hospital.

To finalize this category, we can mention Swanson, in 20162626 Swanson E. Our own worst enemy. Plast Reconstr Surg. 2016 May;137(5):911e-4e., who cites thromboembolism as a feared complication in plastic surgery. The author reports that the procedures are associated several times, increasing the surgical time and the risk of thrombosis. The author also recalls that many doubts arise in the transposition of protocols idealized for surgeries of other specialties, without taking into account the particularities of plastic surgery. The author exemplifies with breast prosthesis surgery. The patients are at low risk because it is a quick surgery, usually performed on young and thin patients. This fact makes it seems that the opposite, overweight male patients in long surgeries, would have a higher risk, but the correlation, according to the author, is not necessarily true.

In 2016, Swanson2626 Swanson E. Our own worst enemy. Plast Reconstr Surg. 2016 May;137(5):911e-4e. recalled that the pneumatic boot for intermittent compression of the lower limbs presents conflicting studies. Although it appears that it reduces the appearance of deep vein thrombosis (DVT) by up to 60%, it would increase cases of pulmonary embolism by 12% with its use. Another question that the author raises would be related to the combined procedures. It seems that the combination of surgical times would increase the risk of thrombosis, however, if we consider the sum of the two surgical procedures performed individually, the author says that the patient would have a higher risk of thromboembolic events. Caprini’s own score, widely used in risk stratification of surgical patients for thrombotic events, according to the author, is questionable, as it is an uncontrolled and randomized study with a 2C degree of recommendation. The author also points out that the clotting tests, Prothrombin Activation Time (PAT) and Thromboplastin Partial Activation Time (PTT), which are routinely ordered and do not diagnose various genetic disorders that interfere with coagulation.

CONCLUSION

In this systematic review, the countries that most published on the subject were the United States and Brazil. The most frequently encountered concern was safety related to the training of plastic surgery residents. Tools such as the checklist have also been used to improve security. Another concern that requires further studies would be whether the weekends present more significant complications in relation to surgeries performed during the week, precisely because there is a lack of evidence considering the particularities of plastic surgery patients. These particularities are also remembered in the prevention of thromboembolism, and further studies are recommended taking into account the particularities of patients in this specialty for the prevention of thromboembolism. However, it seems to have more solid foundations in patient safety, the well-formulated medical record, as well as the informed consent form. Pre-anesthetic consultation also seems to favor patient safety.

Moreover, finally, just as surgical procedures evolve towards better safety, so do new technologies, such as the use of WhatsApp. The use of this tool seems to be safe and seems to increase the attendance of the medical team by improving the team’s communication.

It appears that, when studying these 15 articles, there is no way to identify a unique way to answer the research question: “What are the actions related to patient safety in plastic surgery?”, Because the authors found in searches in databases, data pointed to varied needs and discussed different focuses of attention.

Evident is the importance of new and other more in-depth studies to achieve the subject of patient safety in plastic surgery, in order to favor health care. It is essential to reinforce the patient’s safe practice in any healthcare environment, to minimize risks and damage to the patient. It is considered that the few articles found explicitly on safety in plastic surgery may reveal that there is a lack of reflections in this regard. The various specificities of these patients must be considered, such as the fact that they are generally female, healthy, and young. Also, the specific considerations of the specialty, such as intolerance to any adverse effect precisely because of the profile of patients it treats. Therefore, it is essential to do more research on the subject to avoid disorders and promote better treatment of patients.

From a future perspective, it can be considered that the field of operation of plastic surgery and the assumptions of patient safety are certainly fertile fields, not only in health care but also in teaching. Professional training must be carried out in such a way as to enable the future doctor to develop unequivocal skills on the subject.

The subject of patient safety should be transversal to the undergraduate medical curriculum, allowing that, in specialization, the fundamental principles about safety are rooted in the professional, becoming a culture of safety.

The teaching of the theme would bring effectiveness to health actions, and this reflection could be brought up in educational institutions. For this researcher, it is reiterated that knowing the theme, identifying the low intellectual production, led to reconsider the attitude towards the daily performance in the act of teaching patient safety, not only in plastic surgery, but as an interdisciplinary theme.

    COLLABORATIONS
  • OHMS  Analysis and/or data interpretation, Conception and design study, Conceptualization, Data Curation, Final manuscript approval, Investigation, Writing - Review & Editing
  • ERR  Final manuscript approval, Methodology, Supervision, Writing - Original Draft Preparation
  • JCM  Final manuscript approval, Writing - Original Draft Preparation, Writing - Review & Editing
  • ICMMC  Analysis and/or data interpretation, Conceptualization, Final manuscript approval, Methodology, Supervision, Writing - Review & Editing
  • Institution: Faculdades Pequeno Príncipe, Curitiba, PR, Brazil.

REFERÊNCIAS

  • 1
    Reis CT, Martins M, Laguardia J. A segurança do paciente como dimensão da qualidade do cuidado de saúde: um olhar sobre a literatura TT. Ciênc Saúde Coletiva. 2013;18(7):2029-36.
  • 2
    Saldanha OR, Salles AG, Ilaverias F, Saldanha Filho OR, Saldanha CB. Fatores preditivos de complicações em procedimentos da cirurgia plástica sugestão de escore de segurança. Rev Bras Cir Plást. 2014;29(1):105-13.
  • 3
    Souza P, Mendes W. Segurança do paciente. Rio de Janeiro: Fiocruz; 2014.
  • 4
    World Health Organization (WHO). Summary of the evidence on patient safety: implications for research. Geneva: WHO; 2008.
  • 5
    World Health Organization (WHO). World alliance for patient safety. Implementation manual surgical safety checklist. Safe Surgery saves lives. Geneva: WHO; 2008.
  • 6
    Monteiro F, Silva LR. "Checklist" lista de verificação de segurança cirúrgica: avaliação e intervenção. Rev Ciênc Méd Biol. 2013;12(4):482-5.
  • 7
    Ministério da Saúde (BR). Agência Nacional de Vigilância Sanitária. Segurança do paciente e qualidade em serviços de saúde: uma reflexão teórica aplicada à prática. Brasília (DF): Ministério da Saúde; 2013.
  • 8
    Ferraz EM. A cirurgia segura: uma exigência do século XXI. Rev Col Bras Cir. 2009;39(4):281-2.
  • 9
    Alpendre FT, Cruz E, Dyniewicz AM, Mantovani MF, Silva AE, Santos GS. Safe surgery: validation of pre and postoperative checklists. Rev Latino- Am Enfermagem. 2017;25:e2907.
  • 10
    World Health Organization (WHO). WHO guidelines for safe surgery: safe surgery saves lives. Geneva: WHO; 2009.
  • 11
    Sampaio RF, Mancini MC. Estudos de revisão sistemática: um guia para síntese criteriosa da evidência científica. Rev Bras Fisioter. 2007;11(1):83-9.
  • 12
    Doncatto LF. Uso do termo de consentimento informado em cirurgia plástica estética. Rev Bras Cir Plást. 2012;27(3):353-8.
  • 13
    Schwartzman UP, Batista KT, Duarte LTD, Teixeira D, Saraiva RA, Fernandes MC, et al. Complicações anestésicas em Cirurgia Plástica e a importância da consulta pré-anestésica como instrumento de segurança. Rev Bras Cir Plást. 2011;26(2):221-7.
  • 14
    Rezaeian F, Schantz JT, Sukhova I, Schenck TL, GIunta RE, Harder Y, et al. Training in aesthetic surgery at a university clinic - the Munich model. Handchir Mikrochir Plast Chir. 2013 Oct;45(6):370-5.
  • 15
    Prates CG, Stadñik CMB, BagatinI A, Caregnato RC, Moura GMSS. Comparação das taxas de infecção cirúrgica após implantação do checklist de segurança. Acta Paulista Enfermagem. 2018;31(2):116-22.
  • 16
    Sucupira E, Matta R, Zuker P, Matta J, Arbeláez JP, UebeL CO. Aesthetic plastic surgery checklist: a safety tool. Aesthetic Plast Surg. 2016 Oct;40(5):785-91.
  • 17
    Amorim Filho HC, Amorim CCB. Lipoabdominoplastia no tratamento estético do abdome: experiência de 5 anos. Rev Bras Cir Plást. 2012;27(2):301-8.
  • 18
    Hernandez-Boussard T, McDonald KM, Rhoads KF, Curtin CM. Patient safety in plastic surgery: identifying areas for quality improvement efforts. Ann Plast Surg. 2015 May;74(5):597-602.
  • 19
    Sidhoum N, Dast S, Abdulshakoor A, Assaf N, Herlin C, Sinna R. WhatsApp: improvement tool for surgical team communication. J Plast Reconstr Aesthet Surg. 2016 Nov;69(11):1562-3.
  • 20
    Tadisina KK, Chopra K, Singh DP. The "weekend effect" in plastic surgery: analyzing weekday versus weekend admissions in body contouring procedures from 2000 to 2010. Aesthet Surg J. 2015;35(8):995-8.
  • 21
    Koulaxouzidis G, Momeni A, Simunovic F, Lampert F, Bannasch H, Stark . GB. Aesthetic surgery performed by plastic surgery residents: an analysis of safety and patient satisfaction. Ann Plast Surg. 2014;73(6):696-700.
  • 22
    Massenburg BB, Sanati-Mehrizy P, Jablonka EM, Taub PJ. The impact of resident participation in outpatient plastic surgical procedures. Aesthetic Plast Surg. 2015;40(4):584-91.
  • 23
    Qureshi AA, Parikh RP, Myckatyn TM, Tenenbaum MM. Resident cosmetic clinic: practice patterns, safety, and outcomes at an academic plastic surgery institution. Aesthet Surg J. 2016 Oct;36(9):NP273-80.
  • 24
    Parikh PR, Snyder-Warwick A, Naidoo S, Skolnick GB, Patel KB. Impact of an event reporting system on resident complication reporting in plastic surgery training: addressing an ACGME and Plastic Surgery Milestone Project Core Competency. Plast Reconstr Surg. 2017 Nov;140(5):736e-45e.
  • 25
    Kittinger BJ, Matejicka II A, Mahabir RC. Surgical precision in clinical documentation connects patient safety, quality of care, and reimbursement. Perspect Health Inf Manag. 2016 Jan;13:1.
  • 26
    Swanson E. Our own worst enemy. Plast Reconstr Surg. 2016 May;137(5):911e-4e.

Publication Dates

  • Publication in this collection
    29 May 2023
  • Date of issue
    Apr-Jun 2020

History

  • Received
    15 July 2019
  • Accepted
    29 Feb 2020
Sociedade Brasileira de Cirurgia Plástica Rua Funchal, 129 - 2º Andar / cep: 04551-060, São Paulo - SP / Brasil, Tel: +55 (11) 3044-0000 - São Paulo - SP - Brazil
E-mail: rbcp@cirurgiaplastica.org.br