Safe surgery: analysis of physicians’ adherence to protocols, and its potential impact on patient safety

Objectives: to identify surgeons’ knowledge and compliance rate to the Safe Surgery Protocol, as well as to assess the incidence of surgery-related adverse events, including patients’ knowledge about the protocol. Methods: this is a cross-sectional and prospective study. An instrument was developed to collect the socio-graphic characteristics of sixty-eight surgeons and residents, their knowledge and adherence to the safe surgery protocol. Eighty-two patients were assessed regarding their awareness about the surgical procedure. The operating environment was also evaluated. Descriptive statistics and the odds ratio are presented. Results: the surgeons, despite their previous contact with the protocol throughout the graduation period, were poorly compliant with it. Adverse events such as the use of uncalibrated equipments or the presence of foreign bodies in several equipments such as drills and cautery pens were identified. In addition, some of the adverse events were identified and fixed, after patients had already been anesthesized, but before the beginning of the surgical procedure. Patients demonstrated knowledge about the operation they would undergo, but they did not know about its duration, and they were not introduced to the surgical team. Conclusion: there were failures in the dynamics and compliance regarding some phases of the protocol, which may impact the laterality errors and patient safety.

Rev Col Bras Cir 47:e20202429 be prevented worldwide. Adverse events have been estimated to affect 3-16% of all hospitalized patients, and more than half of these events are known to be preventable. Despite the considerable improvement in knowledge about surgical safety, at least half of the adverse events occur during the operation. Assuming a perioperative adverse event rate of 3% and a mortality rate of 0.5%, worldwide almost 7 million surgical patients will suffer significant complications each year, 1 million of whom will die during or immediately after the operation 6 .
In October of 2004, the WHO created the World Alliance for Patient Safety, which, from 2005 on, has tackled priority topics to be addressed every two years, known as Global Challenges 7  There are at least four underlying challenges to improve surgical safety. First, it has not been recognized as a relevant public health issue, yet. The second problem is that the lack of access to basic surgical care remains a concern in low-income settings. In fact, the simultaneous need for initiatives to improve the safety and reliability of surgical interventions has not been widely recognized.
The third underlying problem in ensuring surgical safety is that existing safety practices seem not have been adopted by many countries. Thus, surgical site infection, for example, remains one of the most common causes of surgical complications. The fourth underlying problem for improving surgical safety is its complexity. Even the simplest procedures involve dozens of critical steps, each with chances of failure, and the potential to cause injury to patients 6 .
These factors encompass the various dimensions of patient safety culture that an organization should establish and follow over the years. Furthermore, there is another aspect of the safety culture that is very strong in the healthcare process: the belief that healthcare professionals are infallible and, with that, the adverse events, with or without harm, are still little reported by professionals, because they fear their competence can be questioned.
Therefore, based on the number of adverse events that still occur, even after the introduction of the Safe Surgery Protocol proposed by the ANVISA, our goal is to analyze the compliance and knowledge about the WHO Safe Surgery Protocol by surgeons in two hospitals, in a city in the northwestern of São Paulo state. Therefore, we sought to identify, characterize, and understand noncompliances to the protocol, as well as to identify adverse events related to the surgical procedures, and highlight initiatives that may change this scenario. We also aimed to identify the knowledge and the compliance to the Safe Surgery Protocol by attendings and residents of surgery, as well as the incidence of adverse events related to the procedures.

METHODS
This is a cross-sectional and prospective study. The instrument was validated based on its objectivity, clarity, and specificity. Two surgeons and two nurse specialists in patient safety participated in the process, which also considered the practical applicability of the instrument.
Any surgical specialty procedure was included. When checking the medical records, 67.94% of the patients were not prescribed antibiotic prophylaxis, as this was not prescribed by the doctor responsible for the operation, and 82.05% did not have blood bank reservation.
Patients were excluded if they were unconscious or had mental impairment which would impact their answers.
Those who did not consent to participate and did not sign the IC were also excluded.
The results were analyzed using descriptive statistics and odds ratio (OR) with a 95% confidence interval (CI).      During the pre and intraoperative periods, the surgeon may face several adversities, such as: lack of workups, lack of evaluation and control of comorbidities, lack or failure of equipment, and lack of materials. However, our data showed that most of these adverse events did not happen when the patient had already been anesthetized.
Regarding the patients, most of them knew the procedure they were undergoing, but they were not aware about the duration of the procedure as well as the type of anesthesia. Also, communication failure became \ evident when patients reported not having been introduced to the surgical team. This result is in accordance with a recent American study on the incidence of adverse events. The researchers observed that the lack of communication was the third problem that most impacts patient safety. The first problem was the execution process, and the second was planning and problem-solving 11 .
Regarding that indicates strategies to be adopted in all the operation and considering the anatomic regions in order to avoid infections and ensure patient safety 13 . However, in some cases, antibiotic prophylaxis was not necessary. Regarding the observed failure in blood reservations, it should be disclosed that in the current study most of the procedure were of low complexity, which might explain why for some patients this was not performed.

CONCLUSION
Our data showed safe surgery checklists in the two hospitals are a routine. However, there are significant flaws in all the different stages of its application. We observed an indirect association between time since physicians' graduation and knowledge about the safety protocol, which demonstrates the recent implementation of this concept in the regional medical courses.