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Providing Care That Is Safe

D1. What Is The Risk Of Our Patients Experiencing A Fall?

Studies have revealed that 1 in 3 elderly people experience a fall at least once a year. The risk could increase 2-3 times when people get sick and hospitalised[1]. A fall experienced by a sick patient tends to result in more serious complications such as fractures and/or lacerations. Nowadays most hospitals regard fall prevention as one of their highest safety priorities for patients. The rate of in-hospital fall was 1.03 per 1000 days of hospital stay for geriatric patients in SGH, while the hospital-wide fall rate was 0.97. Our fall rate was 3-4 times lower compared to the rates reported in the United States[2]  and England[3].

1. Clinical Practice Guideline for the Assessment and Prevention of Falls in Older People2004: London.
2. Hitcho EB, K.M., Birge S, Claiborne Dunagan W, Fischer I, Johnson S, et al. , Characteristics and circumstances of falls in a hospital setting: a prospective analysis. J Gen Intern Med 2004. 19(7): p. 8.
3. Healey, F., et al., Falls in English and Welsh hospitals: a national observational study based on retrospective analysis of 12 months of patient safety incident reports. Quality & safety in health care, 2008. 17(6): p. 424-30.

D2. What Is The Risk Of Severe, Uncontrolled Bleeding After Tonsillectomy?

A tonsillectomy is a surgery undertaken to remove tonsils that are prone to recurrent infections. A potentially serious complication of this surgery is severe, uncontrolled bleeding over the wound site after the operation.

From January 2011 to present, only 2.8% (14 out of total 505 tonsillectomies) of patients experienced bleeding that required hospital readmissions to undergo surgical procedures to stop the bleeding. Overall, our rate was compared well or lowered than the rates reported from Austria and United States.

1. Stephanie Sarny,Guenther Ossimitz, Walter Habermann, Heinz Stammberger. Hemorrhage Following Tonsil Surgery: A Multicenter Prospective Study. Laryngoscope, 2011; 121:2553–2560.
2. Neil Bhattacharyya, MD, FACS; Lynn J. Kepnes, ANP Revisits and Postoperative Hemorrhage After Adult Tonsillectomy. Laryngoscope, 2014; 124:1554–1556

D3. What Is The Chance Of Keyhole Cholecystectomy Being Converted To Open Cholecystectomy?

Open cholecystectomy is a traditional abdominal surgery to remove the gallbladder through a wide incision. Laparoscopic cholecystectomy, a modern surgical technique, needs only a tiny open and has become the customary method to treat gallstones. However, in view of the difficulty of the procedure and the experience of surgeons, laparoscopic cholecystectomy could be associated with serious postoperative complications, such as bile leakage, haemorrhage, sub-hepatic abscess, making the additional open surgery necessary for complication management. From January 2010 to present, there was no occurrence of bile duct injury after laparoscopic cholecystectomy in SGH. The incidence of uncontrolled bleeding was also very low.

1. Aires de Sousa, M. and H. de Lencastre, Bridges from hospitals to the laboratory: genetic portraits of methicillin-resistant Staphylococcus aureus clones. FEMS immunology and medical microbiology, 2004. 40(2): p. 101-11.
2. Chen, Y.Y., Y.C. Chou, and P. Chou, Impact of nosocomial infection on cost of illness and length of stay in intensive care units. Infection control and hospital epidemiology : the official journal of the Society of Hospital Epidemiologists of America, 2005. 26(3): p. 281-7.

D4. What Is The Risk Of Our Patients Acquiring An Infection Caused By Methicillin-Resistant Staphylococcus Aureus (MRSA)?

Healthcare-associated bloodstream infections (bacteraemia) with methicillin-resistant Staphylococcus aureus (MRSA) is becoming a major public health problem [1]. MRSA is a hard-to-treat bacteria due to the resistance to certain antibiotics [2]. MRSA infections in hospitals and healthcare facilities are often associated with suboptimal hand hygiene and infection control practices and patients’ underlying medical conditions. In SGH, multi-pronged measures, including hand hygiene, environmental hygiene, active screening for MRSA for high risk patient populations at time of admission or before major surgical procedures, and contact precautions during the management of MRSA patients, have been effectively taken. All these measures have collectively led to a sustained and successful reduction in the incidence of MRSA bacteraemia in SGH from year 2007 to 2013.

*Source: Department of Infection Control. SGH

1. Chen, Y.Y., Y.C. Chou, and P. Chou, Impact of nosocomial infection on cost of illness and length of stay in intensive care units. Infect Control Hosp Epidemiol, 2005. 26(3): p. 281-7.
2. Aires de Sousa, M. and H. de Lencastre, Bridges from hospitals to the laboratory: genetic portraits of methicillin-resistant Staphylococcus aureus clones. FEMS Immunol Med Microbiol, 2004. 40(2): p. 101-11.

D5. What Is The Risk Of Our Patients Developing a Post-Injection Joint Infection?

Joint aspirations and injections are common medical procedures for diagnosis and treatment. The aspirated fluid can be used for laboratory testing; meanwhile, the procedure reduces joint swelling. Joint injection is an effective way to deliver medication to an affected area. Joint injections are often applied to patients with arthritis (e.g. rheumatoid arthritis or osteoarthritis) or rheumatism. A rare, but serious complication of joint aspirations and injections are joint infections. The reported incidence in United States was 1:3,000 – 1:50,000 [1]. A clinical audit conducted by the department of Rheumatology and Immunology of SGH revealed that none of our patients developed joint infection in the two months following the procedure from November 2003 to December 2004, which was consistent with the reported rates from medical literature.

1. Charalambous, C.P., et al., Septic arthritis following intra-articular steroid injection of the knee--a survey of current practice regarding antiseptic technique used during intra-articular steroid injection of the knee. Clinical rheumatology, 2003. 22(6): p. 386-90.

D6. What Is The Risk of Post-operative Bleeding Requiring Blood Transfusion After Transurethral Resection Of The Prostate (TURP)?

Aging men with non-cancerous enlargement of prostate gland often experience difficulty passing urine. Transurethral resection of the prostate (TURP) is the most common surgical treatment, which cuts away a section of the prostate gland and removes the blockage of urine flow. Bleeding is one of the main complications after the procedure. The graphs below showed the incidence of blood loss requiring transfusion after TURP. Compared to the study performed in Germany, the incidence rate in SGH appeared more favourable [1].

*Data Source: Department of Quality Management, SGH

1. Reich, O., et al., Morbidity, mortality and early outcome of transurethral resection of the prostate: a prospective multicenter evaluation of 10,654 patients. J Urol, 2008. 180(1): p. 246-9.

D7. What Is The Risk Of Excessive Bleeding After A Kidney Biopsy?

Renal biopsy is a medical procedure used to extract renal tissue for laboratory analysis. It provides valuable information on diagnosis and management of the disease. The most commonly used percutaneous renal biopsy is generally safe and effective. However, postoperative bleeding is the common complication. Patients may notice blood in their urine (gross haematuria). By using real time ultrasound-guided percutaneous renal biopsy, the incidence of postoperative gross haematuria has been maintained at below 3.5%, the reported rate by the counterparts in western countries [1]

1. Corapi, K.M., et al., Bleeding complications of native kidney biopsy: a systematic review and meta-analysis. Am J Kidney Dis, 2012. 60(1): p. 62-73.

D8. Do our patients improve in Daily Activity after Cervical Disc Replacement Surgery?

The degeneration of cervical spine intervertebral discs often causes progressive neurological deficits and intractable neck pain [1]. Cervical disc arthroplasty is a surgery to relieve neck pain and restore patients’ daily activity. Neck Disability Index (NDI) is a standard tool for measuring self-rated disability due to neck pain [2]. Successful outcomes are usually defined by a 15-point or greater reduction in NDI after the surgery. The published results from Orthopaedic Surgery, SGH compared well with those reported in the United States [3].

1. Peng, C.W., et al., Intermediate Results of the Prestige LP Cervical Disc Replacement: Clinical and Radiological Analysis With Minimum Two-Year Follow-up. Spine, 2011. 36(2): p. E105-11.
2. Mummaneni, P.V., et al., Clinical and radiographic analysis of cervical disc arthroplasty compared with allograft fusion: a randomized controlled clinical trial. Journal of neurosurgery. Spine, 2007. 6(3): p. 198-209.
3. Vernon, H. and S. Mior, The Neck Disability Index: a study of reliability and validity. Journal of manipulative and physiological therapeutics, 1991. 14(7): p. 409-15.

D9. What is the risk of our patients acquiring Clostridium difficile-associated disease(CDAD)?

Clostridium difficile is a bacterium that can cause symptoms ranging from diarrhoea to life-threatening inflammation of the colon. CDAD mostly affects older patients in hospitals or in long term care facilities and typically occurs after taking antibiotics. Mild illnesses may get better when discontinuing the usage of the antibiotic. However, the severe symptoms may require special treatment. Effective infection control measures and reduction in antibiotic prescription can prevent CDAD. According to the data published in 2011, there was a significant decline in the incidence-density of CDAD over a period of three years from 2006 to 2008 in SGH [1].

1. Hsu, L.Y., et al., Decline in Clostridium difficile-associated disease rates in Singapore public hospitals, 2006 to 2008. BMC research notes, 2011. 4: p. 77.

D10. Are our critically ill patients well protected from Ventilator-Associated Pneumonia (VAP) in MICU?

Ventilator-Associated Pneumonia (VAP) is a common infectious complication among mechanically ventilated patients in intensive care unit (ICU)[1]. VAP is associated with increased morbidity and mortality, prolonged hospital stay and increased hospital costs. The rate of VAP is an important quality indicator for patient care and safety. The incidence of VAP varies in different countries. By limiting ventilator use, employing proper guidelines for hand hygiene and ventilator care, providing good oral care, and other measures, we have successfully maintained the incidence of VAP in MICU of SGH below 2 per 1000 ventilator days since 2007. Especially in the year of 2010 and 2012, we had no VAP occurrence. This stands true especially for the years 2010 and 2012, during which we had no occurrences of VAP.

1. Kollef, M.H., et al., The impact of nosocomial infections on patient outcomes following cardiac surgery. Chest, 1997. 112(3): p. 666-75.
2. National Nosocomial Infection Surveillance (NNIS) System Report, data summary January 1992 through June 2004. Am J Infect Control 2004. 32.
3. Suka, M., et al., Incidence and outcomes of ventilator-associated pneumonia in Japanese intensive care units: the Japanese nosocomial infection surveillance system. Infection control and hospital epidemiology : the official journal of the Society of Hospital Epidemiologists of America, 2007. 28(3): p. 307-13.
4. Vanhems, P., et al., Early-onset ventilator-associated pneumonia incidence in intensive care units: a surveillance-based study. BMC infectious diseases, 2011. 11: p. 236.
5. Muscedere, J.G., C.M. Martin, and D.K. Heyland, The impact of ventilator-associated pneumonia on the Canadian health care system. Journal of critical care, 2008. 23(1): p. 5-10.

D11. What is the risk of our patients in Major Operating Theaters? Standard Operating Protocol ---- Implementation of Correct Procedure at Correct Body Site

SGH implemented the “Performance of correct procedure at correct body site” standard operating procedure (SOP) to minimise the risk of wrong site, wrong procedure or wrong person surgery under the WHO High 5s project in 2009. Direct observations as well as document review were used to measure compliance. For document review, a random sample comprising 20% of all major operating theatre cases were audited each month.

Pre-operative verification process excluding site marking and time-out

In 2011, 98.6% of the surgeries performed in SGH had a complete pre-operative verification process excluding site marking and time-out. This was higher than the averages of Singapore and participating countries, which were 92.8% and 69.4% respectively.

* The group of participating countries in 2009 comprised Australia, Canada, France, Germany, Netherlands, Singapore, United Kingdom and United States. The United Kingdom withdrew due to budget cuts, and Trinidad and Tobago joined the project in 2011.

Properly marked surgical site

More than 99% of the surgeries in SGH had a properly marked surgical site across all months in 2011. The average for Singapore was 87.7%, while it was 65.7% for participating countries.

Complete final time-out

98.5% of the surgeries performed in SGH had a complete final time-out in 2011, compared to Singapore’s average of 95.4% and participating countries’ average of 83.1%.

Notably, in SGH, all surgeries performed in major operating theatres in 2011 were at the correct site. There were no cancelled cases due to implementation of the SOP.


This work was carried out as part of the High 5s Project set up by the World Health Organization in 2007  and coordinated  globally by the WHO Collaborating Centre for Patient Safety, The Joint Commission in the United States of America, with the participation of the following Lead Technical Agencies including: Australian Commission on Safety and Quality in Healthcare Care, Australia; Canadian Patient Safety Institute, Canada;  National Authority for Health-HAS, France, EVALOR (EVAluation LORraine), France ( from 2009 -2011) OMEDIT Aquitaine (Observatoire du Medicament,  Dispositi fs medicaux et  Innovation Therapeutique), France (from 2011-2015)  and CEPPRAL-Qualité et Sécurité en santé, France; German Agency for Quality in Medicine, Germany and the German Coalition for Patient Safety, Germany; CBO (a TNO company) Dutch Institute for Healthcare Improvement, the Netherlands;  Singapore Ministry of Health, Singapore; Trinidad and Tobago Ministry of Health, Trinidad & Tobago; National Patient Safety Agency, United Kingdom ; and the Agency for Healthcare Research and Quality, USA.












D12. Is Skin Biopsy Safe in SGH?

Skin biopsy is one of the most important diagnostic tests for skin disorders, in which a small sample of skin tissue is removed and processed for testing or examination. Skin biopsy, in general, is a safe and straightforward procedure. However, multiple factors influence the risk of postoperative wound complications, which mainly include unexpected bleeding, would infection and delayed healing. In year 2011 and 2012, more than 1000 skin biopsy procedures have been performed by the specialists in the Dermatology Unit, SGH. There was no reported unexpected bleeding and delayed healing. The incidence of wound infection was 1%, which is lower than 5%, the acceptable rate of infection suggested worldwide after clean minor surgery.

*Source: Dermatology Unit, SGH
1. Heal, C., P. Buettner, and S. Browning, Risk factors for wound infection after minor surgery in general practice. The Medical journal of Australia, 2006. 185(5): p. 255-8.
2. Dixon, A.J., et al., Prospective study of wound infections in dermatologic surgery in the absence of prophylactic antibiotics. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.], 2006. 32(6): p. 819-26; discussion 826-7.
3. Rogues, A.M., et al., Infection control practices and infectious complications in dermatological surgery. The Journal of hospital infection, 2007. 65(3): p. 258-63.



Last Modified Date :05 May 2015