text:
WHO Guidelines for Safe Surgery
- Baldwin Townsend
- 3 years ago
- Views:
1 World Alliance for Patient Safety WHO Guidelines for Safe Surgery (First Edition)
2 The WHO Guidelines for Safe Surgery, First Edition, is intended to be issued as a Second Edition in At present it is important for countries and organizations to note that the guidelines represent a consensus of international experts and up to date technical information on safe surgery across the world. The guidelines are being implemented for testing purposes in several hospitals across the six WHO regions and changes may be made to some of the technical content of the chapters in light of results. We welcome formal feedback on these guidelines. Feedback is invited using the AGREE methodology WHO/IER/PSP/ E World Health Organization 2008 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: ; fax: ; Requests for permission to reproduce or translate WHO publications whether for sale or for noncommercial distribution should be addressed to WHO Press, at the above address (fax: ; The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in the United States of America
3 3 Table of contents Section I. Introduction 7 The problem: Complications of surgical care have become a major cause of death and disability worldwide 8 The Safe Surgery Saves Lives Challenge: Identifying solutions 10 Transformation of risk during anaesthesia The time out or surgical pause Use of a checklist for central line insertion The Safe Surgery Saves Lives approach 12 Improvement through the Safe Surgery Saves Lives programme 13 Organization of the guidelines 15 Section II. Ten essential objective for safe surgery: Review of the evidence and recommendations 19 Objective 1: The team will operate on the correct patient at the correct site. 21 The Universal Protocol Step 1. Verification Step 2. Marking Step 3. Time out Recommendations Objective 2: The team will use methods known to prevent harm from administration of anaesthetics, while protecting the patient from pain. 27 Patterns of avoidable morbidity and mortality during anaesthesia Approaches to improving the safety of anaesthesia Evidence on monitoring with pulse oximetry and capnography Expert opinion Controlled trials Incident reporting Inference from data on anaesthesia mortality Other considerations on oximetry and capnography Conclusion Preparation for and delivery of anaesthesia Facilities Anaesthesia equipment Gas supplies in anaesthesia Monitoring Ancillary equipment and medications Infrastructure, supplies and care standards Recommendations Objective 3: The team will recognize and effectively prepare for life-threatening loss of airway or respiratory function. 45 Incidence of difficult and failed airway management Airway assessment Thyromental distance Mallampati classification Management of the airway Face-mask ventilation Supraglottic airway ventilation Endotrachial intubation
4 4 Fibre-optic intubation Aspiration of gastric contents Recommendations Objective 4: The team will recognize and effectively prepare for risk of high blood loss. 57 Resuscitation of hypovolaemic patients Prevention of blood loss Management of blood loss Recommendations Objective 5: The team will avoid inducing an allergic or adverse drug reaction for which the patient is known to be at significant risk. 63 Types of adverse reactions Causes of error in delivery of perioperative medications Recommendations Objective 6: The team will consistently use methods known to minimize the risk for surgical site infection. 69 Pathogenesis and microbiology Prevention and surveillance of surgical site infections Definitions of surgical site infection Superficial incisional surgical site infection Deep incisional surgical site infection Organ space surgical site infection Methods of scoring infection Surveillance of surgical site infections Inpatients Post-discharge Risk factors Blood glucose and risk of infection Oxygen tension and temperature in the perioperative period Presurgical skin disinfection Alcoholic compounds Chlorhexidine Iodophors Triclosan and chloroxylenol Octenidine Special cases for decontamination Vaginal and uterine surgery Digestive-tract surgery Antibiotic prophylaxis Prophylaxis in children Subacute bactieral endocarditis prophylaxis in patients undergoing surgical procedures Minimizing contamination in the operating room Guaranteeing sterility of surgical instruments: sterility indicators Recommendations Objective 7: The team will prevent inadvertent retention of instruments or sponges in surgical wounds. 115 General criteria for counting Sponge count Sharps count Instrument count Documentation of counts
5 5 Count discrepancies Methodical wound exploration before closure Recommendations Objective 8: The team will secure and accurately identify all surgical specimens. 121 Recommendations Objective 9: The team will effectively communicate and exchange critical information on the patient. 123 Team culture and its effects on safety Patterns of communication breakdown Reducing communication breakdown during surgery Use of checklists to improve safety and communication Record-keeping Recommendations Objective 10: Hospitals and public health systems will establish routine surveillance of surgical capacity, volume and results. 133 Feasibility and implications of measurement Infrastructure Economic considerations Positive incentives Negative incentives Case mix and risk adjustment Current measures in surgery Volume Outcome Capacity Surgical surveillance: Surgical vital statistics for systems-level evaluation Basic surgical vital statistics The number of operating rooms in each country The number of surgical procedures performed in operating rooms in each country The numbers of trained surgeons and trained anaesthesia professionals in each country Number of deaths on the day of surgery Number of in-hospital deaths after surgery Intermediate surgical vital statistics Advanced surgical vital statistics Surgical surveillance: Basic patient measures at hospital and practitioner levels Day-of-surgery and postoperative in-hospital mortality rates Surgical site infections The Surgical Apgar Score: a simple outcome score for surgery Findings from international pilot site Future directions of surgical surveillance Recommendations Summary of Recommendations 151 Section III. WHO Surgical Safety Checklist 153 Section IV. Implementation manual for the WHO Surgical Safety Checklist 157 Authors and contributors 167
6 6
7 7 SECTION I. INTRODUCTION Confronted with worldwide evidence of substantial public health harm due to inadequate patient safety, the Fifty-fifth World Health Assembly in 2002 adopted a resolution (WHA55.18) urging countries to strengthen the safety of health care and monitoring systems. The resolution also requested that WHO take a lead in setting global norms and standards and supporting country efforts in preparing patient safety policies and practices. In May 2004, the Fifty-seventh World Health Assembly approved the creation of an international alliance to improve patient safety globally, and the World Alliance for Patient Safety was launched in October For the first time, heads of agencies, policy-makers and patient groups from around the world came together to advance attainment of the goal of First, do no harm and to reduce the adverse consequences of unsafe health care. The purpose of the Alliance is to facilitate patient safety policy and practice. It is concentrating its actions on focused safety campaigns called Global Patient Safety Challenges, coordinating Patients for Patient Safety, developing a standard taxonomy, designing tools for research policy and assessment, identifying solutions for patient safety, and developing reporting and learning initiatives aimed at producing best practice guidelines. Together these efforts could save millions of lives by improving basic health care and halting the diversion of resources from other productive uses. The Global Patient Safety Challenge, a core element of the Alliance, brings together the expertise of specialists to improve the safety of care. The area chosen for the first Challenge, in , was infection associated with health care. This campaign established simple, clear standards for hand hygiene, an educational campaign and WHO s first Guidelines on hand hygiene in health care (advanced draft) (1). The problem area chosen for the second Global Patient Safety Challenge, in , is the safety of surgical care. Preparation of these draft Guidelines on safe surgery followed the steps recommended by WHO (Table I.1). Table I.1 Development of the WHO Safe Surgery Guidelines (2) WHO recommended steps in technical guideline development Define the specific issues to be addressed by the guidelines Undertake a systematic search for evidence Review the evidence available Develop recommendations linked to the strength of the evidence Draft guidelines Discuss and incorporate, where relevant, comments of external reviewers Draft final version of the guidelines Make recommendations on dissemination strategy Document the process of guideline development Test the guidelines through pilot evaluations Action Taken Completed Completed Completed Completed Completed Completed Completed Completed Completed In Progress
8 8 The groundwork for the project began in autumn 2006 and included an international consultation meeting held in January 2007 attended by experts from around the world. Following this meeting, expert working groups were created to coordinate a review of the available scientific evidence, the writing of the guidelines document and discussion among the authors. Nearly 100 international experts contributed to the document (see end). The guidelines are being pilot tested in each of the six WHO regions an essential part of the Challenge to obtain local information on the resources required to comply with the recommendations and information on the feasibility, validity, reliability and cost effectiveness of the interventions. The problem: Complications of surgical care have become a major cause of death and disability worldwide. Data from 56 countries showed that in 2004 the annual volume of major surgery was an estimated 187 million 281 million operations (3), or approximately one operation annually for every 25 human beings alive. This is a large and previously unappreciated volume with significant implications for public health. It is almost double the annual volume of childbirths in 2006, there were approximately 136 million births (4) and is at least an order of magnitude more dangerous. While the rates of death and complications after surgery are difficult to compare since the case mix is so diverse, in industrialized countries the rate of major complications has been documented to occur in 3 16% of inpatient surgical procedures, and the death rate % (5,6). Nearly half the adverse events in these studies were determined to be preventable. Studies in developing countries suggest a death rate of 5 10% associated with major surgery (7 9), and the rate of mortality during general anaesthesia is reported to be as high as 1 in 150 in parts of sub-saharan Africa (10). Infections and other postoperative complications are also a serious concern around the world. Avoidable surgical complications thus account for a large proportion of preventable medical injuries and deaths globally. Adverse events have been estimated to affect 3 16% of all hospitalized patients (11 14), and more than half of such events are known to be preventable. Despite dramatic improvements in surgical safety knowledge, at least half of the events occur during surgical care (5,6). Assuming a 3% perioperative adverse event rate and a 0.5% mortality rate globally, almost 7 million surgical patients would suffer significant complications each year, 1 million of whom would die during or immediately after surgery. Surgical safety has therefore emerged as a significant global public health concern. Just as public health interventions and educational projects have dramatically improved maternal and neonatal survival (15), analogous efforts might improve surgical safety and quality of care. There are at least four underlying challenges to improving surgical safety. First, it has not been recognized as a significant public health concern. Because of the often high expense of surgical care, it is assumed to be of limited relevance in poor- and middle-income countries; however, the WHO Global burden of disease report in 2002 (16) showed that a significant proportion of the disability from disease in the world is due to conditions that are treatable by surgical intervention. Debas and colleagues (17) estimated that 11% of the 1.5 billion
9 9 disability-adjusted life years 1 are due to diseases treatable by surgery. An estimated 63 million people a year undergo surgical treatment for traumatic injuries, 31 million for malignancies and 10 million for obstetric complications (18). Problems associated with surgical safety are well recognized in developed and developing countries alike. In the developing world, the poor state of infrastructure and equipment, unreliable supplies and quality of medications, shortcomings in organizational management and infection control, difficulties in the supply and training of personnel and severe under-financing contribute to the difficulties. For more than a century, surgery has been an essential component of public health. As longevity increases worldwide, its role is increasing rapidly. Lack of access to basic surgical care remains a major concern in low-income settings, and WHO s Global Initiative on Emergency and Essential Surgical Care has made improved access its central mission (19). The parallel requirement for measures to improve the safety and reliability of surgical interventions, however, has gone largely unrecognized. The second underlying problem in improving surgical safety has been a paucity of basic data. Efforts to reduce maternal and neonatal mortality at childbirth have relied critically on routine surveillance of mortality rates and systems of obstetric care, so that successes and failures could be monitored and recognized. Similar surveillance has been widely lacking for surgical care. The WHO Patient Safety Programme found that data on surgical volume were available for only a minority of WHO Member States. The data that were available were not standardized and varied widely in the types of procedures recorded. Even countries in which data on surgical procedures are collected regularly had significant gaps: few reported outpatient surgical procedures, some did not cover specialty procedures such as gynaecological or orthopaedic operations, and most did not cover private hospitals. Data from low- and middleincome countries were often extrapolated from regional data or studies published for other purposes. Virtually none of the countries had reliable information on inpatient death rates or other measures of adverse outcome. The third underlying problem in ensuring surgical safety is that existing safety practices do not appear to be used reliably in any country. Lack of resources is an issue in low-income settings, but it is not necessarily the most important one. Surgical site infection, for example, remains one of the most common causes of serious surgical complications, yet evidence indicates that proven measures such as antibiotic prophylaxis immediately before incision and confirmation of effective sterilization of instruments are inconsistently followed. This is not because of cost but because of poor systematization. Antibiotics, for example, are given perioperatively in both rich and poor countries, but in both they are often administered too early, too late or erratically. Complications of anaesthesia also remain a substantial cause of death during surgery globally, despite safety and monitoring standards which have reduced 1 The disability-adjusted life year (DALY) is an indicator of the time lived with a disability and the time lost due to premature mortality. It extends the concept of potential years of life lost due to premature death to include equivalent years of healthy life lost by virtue of being in states of poor health or disability (World Bank working paper, accessed 12 December 2006; and WHO Health Information Systems and Statistics, accessed 12 December 2006).
10 10 the numbers of unnecessary deaths and disabilities in industrialized countries. Three decades ago, a healthy patient undergoing general anaesthesia had an estimated 1 in 5000 chance of dying from complications of anaesthesia (20). With improved knowledge and basic standards of care, the risk has dropped to 1 in in the industrialized world a 40-fold improvement. Unfortunately, the rate of avoidable death associated with anaesthesia in developing countries is times this rate. Published series showing avoidable anaesthesia mortality rates of 1:3000 in Zimbabwe (21), 1:1900 in Zambia (22), 1:500 in Malawi (23) and 1:150 in Togo (10) demonstrate a serious, sustained absence of safe anaesthesia for surgery. The fourth underlying problem in improving surgical safety is its complexity. Even the most straightforward procedures involve dozens of critical steps, each with an opportunity for failure and the potential for injury to patients, from identifying the patient and the operative site correctly, to providing appropriate sterilization of equipment, to following the multiple steps involved in safe administration of anaesthesia, to orchestrating the operation. The most critical resource of operating teams is the team itself the surgeons, anaesthesia professionals, nurses and others. A team that works effectively together to use its knowledge and abilities on behalf of the surgical patient can avert a considerable proportion of life-threatening complications. Yet, operatingroom personnel have had little guidance or structure for fostering effective teamwork and thus minimizing the risks for surgical safety. The aim of the Safe Surgery Saves Lives programme is to remedy these problems. The Safe Surgery Saves Lives Challenge: Identifying solutions The goal of the Safe Surgery Saves Lives Challenge is to improve the safety of surgical care around the world by defining a core set of safety standards that can be appied in all countries and settings. Working groups of international experts were created to review the literature and the experiences of clinicians around the world and to achieve consensus on safety practice in four topic areas: teamwork, anaesthesia, prevention of surgical site infection and measurement of surgical services. Contributors with expertise in surgery, anaesthesia, nursing, infectious diseases, epidemiology, biomedical engineering, health systems, quality improvement and other related fields, as well as patients and patient safety groups, were recruited from each of the WHO regions; they themselves solicited further input from practitioners and other stakeholders worldwide. At the first consultation in January 2007, difficulties in improving surgical safety were identified and reviewed. Surgery was defined as any procedure occurring in the operating room involving the incision, excision, manipulation or suturing of tissue that usually requires regional or general anaesthesia or profound sedation to control pain. It was recognized that, in surgery, there is no single remedy that would change safety. Safety in surgery requires the reliable execution of multiple necessary steps in care, not just by the surgeon but by a team of health-care professionals working in concert for the benefit of the patient. It was recognized that reliability in other medical fields for example, obstetrics and medication administration has been improved by identifying the basic components of care to be provided and by standardizing routines with tools such as checklists. Three examples of particular relevance are described below.
11 11 Transformation of risk during anaesthesia: No single improvement in the care of surgical patients has had as profound an impact as the advancement of safe practices in anaesthesia. Anaesthesia is dangerous to patients in a number of ways. Respiratory suppression by an anaesthetic leads to hypoxia, while manoeuvres to control the airway can lead to injury. Aspiration is a significant risk for all patients undergoing sedation or anaesthesia. Hypo- and hypertension, cardiac depression or elevation, and medication reactions and interactions are also potential life-threatening problems. Anaesthesia was long considered more dangerous than surgery itself, but a systematic approach to identifying and addressing failures in anaesthesia care has resulted in a sustained, marked reduction in risk in industrialized countries during the past two decades. Anaesthesia experts reviewed lessons from aviation, nuclear power and other industries known as high-reliability organizations, which have five identifiable qualities that define their performance: preoccupation with failure, reluctance to simplify interpretations, sensitivity to operation, commitment to resilience and deference to expertise (24). Leaders in anaesthesia therefore began by acknowledging the persistence of human error. Researchers studied individual incidents in detail and enumerated a list of contributory factors, which included inadequate experience, inadequate familiarity with equipment, poor communication among team members, haste, inattention, fatigue and poor equipment design (25). Through national professional societies, first in the United States and then across Europe and in other industrialized countries, a system of improved anaesthesia care was designed. The specific standards of practice mandate that anaesthetists never leave a patient unattended and always monitor vital signs in a prescribed minimum regimen. Changes were made in technological and engineering design, and manufacturing standards for anaesthesia equipment were established with fallible human beings in mind. For example, the sequence and size of dials were standardized, as was the direction for turning them on and off; locks were incorporated to prevent accidental administration of more than one anaesthetic gas; controls were changed so that the concentration of oxygen delivered could not be reduced below its concentration in room air. Most recently, pulse oximeters and capnographs have been designated as essential instruments for monitoring anaesthesia. Since these changes, deaths due to misconnection of the breathing system or intubating the oesophagus rather than the trachea have become virtually unknown instead of being common causes of death during anaesthesia. In a single decade, the overall death rate associated with general anaesthesia in industrialized nations dropped by more than 95% from one in 5000 cases to one in (26). The time out or surgical pause : In surgery, there are few examples of systematic improvements in safety; however, over the past 5 years in the United States and other industrialized countries, a time out or surgical pause has been introduced as a standard component of surgical care (27). This is a brief, less than 1-min pause in operating-room activity immediately before incision, at which time all members of the operating team surgeons, anaesthesia professionals, nurses and anyone else involved verbally confirm the identity of the patient, the operative site and the procedure to be performed. It is a means of ensuring clear communication among team members and avoiding wrong-site or
12 12 wrong-patient errors. It has been made mandatory in the United States and a few other countries. Further experiments with this procedure have resulted in what has been called an extended pause, during which more protective measures are taken (28). This involves confirmation not only the identity of the patient and the surgical site, but also discussion by team members of the critical details of the operation to be performed. Open communication and improved teamwork are encouraged (29,30). In studies in single institutions, the extended pause has been shown to improve safety and is associated with improved choice and timing of prophylactic antibiotics and appropriate maintenance of intraoperative temperature and glycaemia (28,31). Use of a checklist for central line insertion: A research team at Johns Hopkins University in the United States reported remarkable success in reducing complications from a simple invasive procedure placement of a central intravenous catheter by implementing a limited checklist of steps (32). The checklist ensured that the clinicians washed their hands before inserting the catheter, avoided using the femoral vein when possible, used chlorhexidine soap to clean the insertion site, put on sterile gloves, gown, hat and mask, covered the patient fully with a sterile barrier drape and, after insertion, checked daily to determine if the catheter could be removed. Use of this checklist in 67 hospitals reduced the rate of catheter-related bloodstream infections by two thirds within 3 months. The average intensive care unit reduced its infection rate from 4% to 0. Over 18 months, the programme saved more than 1500 lives and nearly US$ 200 million. The checklist approach has several advantages. Checklists help memory recall, especially for mundane matters that are easily overlooked in patients with dramatic and distracting conditions. Checklists clarify the minimum expected steps in a complex process. By helping a team work together, checklists establish a higher standard of baseline performance (33). They are particularly applicable to the operating room setting, where checklists have been used successfully around the world, although without clear standards or guidance as to their content. The Safe Surgery Saves Lives approach The Safe Surgery Saves Lives programme aims to improve surgical safety and reduce the number of surgical deaths and complications in four ways: (1) by giving clinicians, hospital administrators and public health officials information on the role and patterns of surgical safety in public health; (2) by defining a minimum set of uniform measures or surgical vital statistics, for national and international surveillance of surgical care; (3) by identifying a simple set of surgical safety standards that can be used in all countries and settings and are compiled in a surgical safety checklist for use in operating rooms; and (4) by testing the checklist and surveillance tools at pilot sites in all WHO regions and then disseminating the checklist to hospitals worldwide.
13 13 The WHO Guidelines for safe surgery are central to this effort. The working groups of the Safe Surgery programme considered a range of potential standards, evaluated the evidence for their inclusion, estimated their possible impact and designed measures to assess their effects on performance and safety. The programme also designed a checklist that can be used by practitioners interested in promoting safety and improving the quality of surgical services. It reinforces established safety practices and ensures beneficial preoperative, intraoperative and postoperative steps are undertaken in a timely and efficient way. Many of the steps are already accepted as routine practice in facilities around the world. The aim is not to prescribe a single manner of implementation or to create a regulatory tool. Rather, by introducing key safety elements into the operating routine, teams could maximize the likelihood of the best outcome for all surgical patients without placing an undue burden on the system or the providers. In nearly all settings, the standards will represent changes in some routines. The standards could, however, result in tangible life-saving improvements in care in all environments, from the richest to the poorest. The Second Global Patient Safety Challenge is based on the recognition that every country can improve the safety of its surgical care. Improvement through the Safe Surgery Saves Lives programme The established framework for safe intraoperative care in hospitals involves a routine sequence of events preoperative evaluation of patients, surgical intervention and preparation for appropriate postoperative care each with specific risks that can be mitigated (Table I.2). In the preoperative phase, obtaining informed consent, confirming patient identity and operative site and the procedure to be undertaken, checking the integrity of the anaesthetic machine and the availability of emergency medications, and adequate preparation for intraoperative events are all amenable to intervention. During the operation, appropriate and judicious use of antibiotics, availability of essential imaging, appropriate patient monitoring, efficient teamwork, competent anaesthetic and surgical judgements, meticulous surgical technique and good communication among surgeons, anaesthesia professionals and nurses are all necessary to ensure a good outcome. After the operation, a clear plan of care, an understanding of intraoperative events and a commitment to high-quality monitoring may all improve the surgical system, thereby promoting patient safety and improving outcomes. There is also a recognized need for trained personnel and functioning resources, such as adequate lighting and sterilization equipment. Finally, safe surgery requires ongoing quality assurance and monitoring.
14 14 Table I.2 The nature of the challenge: Teamwork, safe anaesthesia and prevention of surgical site infection are fundamental to improving the safety of surgery and saving lives. Basic issues of infrastructure must be considered and of the ability to monitor and evaluate any instituted changes must be addressed. Surgical Resources and Environment Trained personnel, clean water, consistent light source, consistent suction, supplemental oxygen, functioning surgical equipment and sterile instruments Prevention of Surgical Site Infection Hand washing Appropriate and judicious use of antibiotics Antiseptic skin preparation Atraumatic wound care Instrument decontamination and sterility Safe Anaesthesia Presence of a trained anaesthesia professional Anaesthesia machine and medication safety check Pulse oximetry Heart rate monitoring Blood pressure monitoring Temperature monitoring Safe Surgical Teams Improved communication Correct patient, site, and procedure Informed consent Availability of all team members Adequate team preparation and planning for the procedure Confirmation of patient allergies Measurement of Surgical Services Quality assurance Peer review Monitoring of outcomes Not all these factors can be addressed within the context of the Safe Surgery programme. The economic and physical resources of national health systems are limited by many factors, including economic development status. The Safe Surgery Saves Lives Challenge is a 2-year initiative, and, early in the investigative phase, the programme team determined that it would be unable to address the issues of resources and infrastructure shortfalls given the budget and time frame of this project. Similarly, although human resources are vital for health delivery and for safe care, improvement will require so much investment in education, infrastructure and training that success is unlikely in the near future. In addition, the significant work performed by many health-care workers who lack credentials but fill an important, even vital need, particularly in resource-limited settings, should not be minimized; but there is no clear consensus on what constitutes appropriate training, how much training is enough and how to measure competence. The absence of such basic information makes it exceedingly difficult to set standards for training and credentialing and ultimately leaves it to governments and professional societies to determine how best to approach these issues, given their resources and needs. In view of the limitations for addressing infrastructure and human resources, the expert working groups determined that the most effective initial intervention would be to establish universal standards for safety for existing surgical teams and their work in the operating room. These standards would be operationalized by wide implementation of a checklist and the creation of basic, standardized measures of surgical services. Universal features, strategies and workflow patterns of the perioperative period are critical for care, prone to failure and amenable to simple improvements.
15 15 The aim of the working groups was to identify potential standards for improvements in four areas: safe surgical teams, by promoting communication among team members to ensure that each preparatory step is accomplished in a timely and adequate fashion with an emphasis on teamwork; safe anaesthesia, by appropriate patient monitoring and advance preparation to identify potentially lethal anaesthetic or resuscitation problems before they cause irreversible harm; prevention of surgical site infection, through antisepsis and control of contamination at all levels of patient care; and measurement of surgical services, by creating public health metrics to measure provision and basic outcomes of surgical care. The Safe Surgery Saves Lives Challenge was further guided by three principles. The first is simplicity. An exhaustive list of standards and guidelines might create a package that would improve patient safety, but such comprehensiveness would be difficult to implement and convey and would probably face significant resistance. The appeal of simplicity in this setting cannot be overstated. Uncomplicated measures will be the easiest to institute and can have profound effects in a variety of settings. The second principle is wide applicability. Focusing on a specific resource milieu would reduce the number of issues (e.g. minimum equipment standards for resource-poor settings), but the goal of the challenge is to reach all environments and settings, from resource rich to resource poor, so that all Member States can be involved. Furthermore, regular failures occur in every setting and environment and are amenable to common solutions. The third is measurability. Measurement of impact is a key component of the Second Challenge. Meaningful metrics must be identified, even if they relate only to surrogate processes, and they must be reasonable and quantifiable by practitioners in all contexts. If the three principles of simplicity, wide applicability and measurability are followed, the goal of successful implementation will be feasible. Organization of the guidelines The guidelines are designed to meet these principles and are organized in three steps. First, the specific objectives for safe surgical care are enumerated. Secondly, the findings from reviews of evidence on and experience with approaches to meeting each of the objectives are described. Lastly, potentially beneficial practices are classified into three categories on the basis of clinical evidence or expert opinion as to their ability to reduce the likelihood of serious, avoidable surgical harm and whether adherence is unlikely to introduce injury or unmanageable cost: highly recommended : a practice that should be in place in every operation; recommended : a practice that is encouraged for every operation; and suggested : a practice that should be considered for any operation While the review was relatively comprehensive, it did not make clear how the findings were to be operationalized. Therefore, at the end of the review for each objective and in order to provide simple means for practitioners to ensure and
16 16 improve standards of safety, we focused on the highly recommended practices and used them to construct two products: a WHO safe surgery checklist and a set of recommended surgical vital statistics for measurement. These guidelines are, as noted, a first edition, and are undergoing final review and testing at pilot sites around the world. Nonetheless, there is wide recognition that every country can improve the safety of its surgical care and that this is a critical matter of public health, affecting hundreds of millions of people worldwide each year. By creating a culture of safety, the World Alliance for Patient Safety and WHO are seeking to promote practice standards that reduce injuries and save lives. References 1. World Health Organization. WHO guidelines on hand hygene in health care (advanced draft). Geneva, World Health Organization, World Health Organization. Guidelines for WHO guidelines. Geneva, Global Programme on Evidence for Health Policy, Weiser T, et al. An estimation of the global volume of surgery. Lancet (accepted for publication). 4. Population Reference Bureau world population data sheet (accessed 12 April 2007). 5. Gawande AA, et al. The incidence and nature of surgical adverse events in Colorado and Utah in Surgery, 1999, 126: Kable AK, Gibberd RW, Spigelman AD. Adverse events in surgical patients in Australia. International Journal of Quality in Health Care, 2002, 14: Bickler SW, Sanno-Duanda B. Epidemiology of paediatric surgical admissions to a government referral hospital in the Gambia. Bulletin of the World Health Organization, 2000, 78: Yii MK, Ng KJ. Risk-adjusted surgical audit with the POSSUM scoring system in a developing country. British Journal of Surgery, 2002, 89: McConkey SJ. Case series of acute abdominal surgery in rural Sierra Leone. World Journal of Surgery, 2002, 26: Ouro-Bang'na Maman AF, et al. Deaths associated with anaesthesia in Togo, West Africa. Tropical Doctor, 2005, 35: Brennan TA, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. New England Journal of Medicine, 1991, 324: Wilson RM, et al. The Quality in Australian Health Care Study. Medical Journal of Australia, 1995, 163: Leape LL, et al. The nature of adverse events in hospitalized patients results of the Harvard Medical Practice Study II. New England Journal of Medicine, 1991, 324: United Kingdom Department of Health. An organization with a memory. London, Ronsmans C, et al. Maternal mortality: who, where, and why. Lancet, 2006, 368: World Health Organization. Global burden of disease estimates, Geneva, (accessed 20 October 2006).
17 Debas H, et al. Surgery. In: Disease control priorities in developing countries, 2nd ed. Washington DC, International Bank for Reconstruction and Development and The World Bank Disease Control Priorities Project, World Health Organization. World Alliance for Patient Safety: forward programme Geneva, World Health Organization. Global initiative for emergency and essential surgical care (GIEESC). Geneva. (accessed 20 March 2008). 20. Leape LL. Error in medicine. Journal of the American Medical Association, 1994, 272: McKenzie AG. Mortality associated with anaesthesia at Zimbabwean teaching hospitals. South African Medical Journal, 1996, 86: Heywood AJ, Wilson IH, Sinclair JR. Perioperative mortality in Zambia. Annals of the Royal College of Surgeons of England, 1989, 71: Hansen D, Gausi SC, Merikebu M. Anaesthesia in Malawi: complications and deaths. Tropical Doctor, 2000, 30: Reason J. Human error. Cambridge, Cambridge University Press, Cooper JB, et al. Preventable anesthesia mishaps: a study of human factors. Anesthesiology, 1978, 49: Pierce EC. The 34th Rovenstine Lecture: 40 years behind the mask safety revisited. Anesthesiology, 1996, 84: Joint Commission. Universal protocol for preventing wrong site, wrong procedure, wrong person surgery (accessed 15 February 2007). 28. Makary MA, et al. Operating room briefings: working on the same page. Joint Commission Journal on Quality and Patient Safety, 2006, 32: Helmreich RL, et al. Preliminary results from the evaluation of cockpit resource management training: performance ratings of flightcrews. Aviation, Space and Environmental Medicine, 1990, 61: Pronovost PJ, et al. Creating high reliability in health care organizations. Health Services Research, 2006, 41: Altpeter T, et al. Expanded surgical time out: a key to real-time data collection and quality improvement. Journal of the American College of Surgeons, 2007, 204: Pronovost P, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. New England Journal of Medicine, 2006, 355: Hales BM, Pronovost PJ. The checklist a tool for error management and performance improvement. Journal of Critical Care, 2006, 21:231 5.
18 18
19 19 SECTION II. TEN ESSENTIAL OBJECTIVES FOR SAFE SURGERY: REVIEW OF THE EVIDENCE AND RECOMMENDATIONS Surgical care is complex and involves dozens of steps which must be optimized for individual patients. In order to minimize unnecessary loss of life and serious complications, operative teams have 10 basic, essential objectives in any surgical case, which the WHO safe surgery guidelines support. 1. The team will operate on the correct patient at the correct site. 2. The team will use methods known to prevent harm from administration of anaesthetics, while protecting the patient from pain. 3. The team will recognize and effectively prepare for life-threatening loss of airway or respiratory function. 4. The team will recognize and effectively prepare for risk of high blood loss. 5. The team will avoid inducing an allergic or adverse drug reaction for which the patient is known to be at significant risk. 6. The team will consistently use methods known to minimize the risk for surgical site infection. 7. The team will prevent inadvertent retention of instruments or sponges in surgical wounds. 8. The team will secure and accurately identify all surgical specimens. 9. The team will effectively communicate and exchange critical information for the safe conduct of the operation. 10. Hospitals and public health systems will establish routine surveillance of surgical capacity, volume and results.
20 20
WHO Guidelines for Safe Surgery 2009. Safe Surgery Saves Lives
WHO Guidelines for Safe Surgery 2009 Safe Surgery Saves Lives WHO Library Cataloguing-in-Publication Data WHO guidelines for safe surgery : 2009 : safe surgery saves lives. «WHO/IER/PSP/2008.08-1E» 1.SurgicalMore information
WORLD ALLIANCE FOR PATIENT SAFETY SAFE SURGERY SAVES LIVES SECOND GLOBAL PATIENT SAFETY CHALLENGE WORLD ALLIANCE FOR PATIENT SAFETY THE SECOND GLOBAL PATIENT SAFETY CHALLENGE SAFE SURGERY SAVES LIVESMore information
Errors in the Operating Room. Patrick E. Voight RN BSN MSA CNOR President Association of perioperative Registered Nurses (AORN)
Errors in the Operating Room Patrick E. Voight RN BSN MSA CNOR President Association of perioperative Registered Nurses (AORN) What What We All We Strive All Strive For: For: Patient Patient Safety SafetyMore information
Translating Evidence to Safer Care Patient Safety Research Introductory Course Session 7 Albert W Wu, MD, MPH Former Senior Adviser, WHO Professor of Health Policy & Management, Johns Hopkins BloombergMore information
Risk Management and Patient Safety Evolution and Progress
Risk Management and Patient Safety Evolution and Progress Madrid February 2005 Charles Vincent Professor of Clinical Safety Research Department of Surgical Oncology & Technology Imperial College LondonMore information
What Is Patient Safety?
Patient Safety Research Introductory Course Session 1 What Is Patient Safety? David W. Bates, MD, MSc External Program Lead for Research, WHO Professor of Medicine, Harvard Medical School Professor ofMore information
WORLD ALLIANCE FOR PATIENT SAFETY IMPLEMENTATION MANUAL SURGICAL SAFETY CHECKLIST (FIRST EDITION) SAFE SURGERY SAVES LIVES WORLD ALLIANCE FOR PATIENT SAFETY IMPLEMENTATION MANUAL WHO SURGICAL SAFETY CHECKLISTMore information
Standards of Practice for Patient Identification, Correct Surgery Site and Correct Surgical Procedure
Standards of Practice for Patient Identification, Correct Surgery Site and Correct Surgical Procedure Introduction The following Standards of Practice were researched and written by the AST Education andMore information
WHO strategy for prevention and control of chronic respiratory diseases
WHO/MNC/CRA/02.1 Original: English WHO strategy for prevention and control of chronic respiratory diseases World Health Organization Management of Noncommunicable Diseases Department Chronic RespiratoryMore information
GLOBAL DATABASE ON BLOOD SAFETY Summary Report 1998 1999 World Health Organization Blood Transfusion Safety 1211 Geneva 27, Switzerland Tel: +41 22 791 4385 Fax: +41 22 791 4836 http://www.who.int/bct/btsMore information
Second round Consultation July 2013. Perioperative Nurses College of NZNO. 1 P a g e. Perioperative Nurses College of NZNO, July 2013,
Proposal of formalising the role and education pathway of the Registered Nurse who is providing anaesthetic assistance to the Anaesthetist within the perioperative continuum. Second round ConsultationMore information
Implementation Manual for the Colorado Surgical Site Checklist
Implementation Manual for the Colorado Surgical Site Checklist Additional Information or Questions: Crystal Berumen, MSPH Director of Patient Safety Initiatives Colorado Hospital Association 7335 E. OrchardMore information
Standards for the NPSA and RCR safety checklist for radiological interventions
Radiology Standards for the NPSA and RCR safety checklist for radiological interventions Board of the Faculty of Clinical Radiology The Royal College of Radiologists Foreword The best radiologist I everMore information
Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage
SIXTY-EIGHTH WORLD HEALTH ASSEMBLY WHA68.15 Agenda item 17.1 26 May 2015 Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage The Sixty-eighthMore information
(Resolutions, recommendations and opinions) RECOMMENDATIONS COUNCIL
3.7.2009 Official Journal of the European Union C 151/1 I (Resolutions, recommendations and opinions) RECOMMENDATIONS COUNCIL COUNCIL RECOMMENDATION of 9 June 2009 on patient safety, including the preventionMore information
Prevention of healthcare associated (nosocomial) infection : Safer surgery overview of strategies
Prevention of healthcare associated (nosocomial) infection : Safer surgery overview of strategies Assoc. Professor John Ferguson May 2011 email@example.com www.tinyurl.com\nepal68 Also seeMore information
Reducing the Risk of Wrong Site Surgery
Joint Commission Center for Transforming Healthcare Reducing the Risk of Wrong Site Surgery Wrong Site Surgery Project Participants The Joint Commission s Center for Transforming Healthcare aims to solveMore information
2011 NATIONAL PATIENT SAFETY GOALS. Created by UMC s Clinical Education & Research Department
2011 NATIONAL PATIENT SAFETY GOALS Created by UMC s Clinical Education & Research Department Background The National Patient Safety Goals (NPSG) were established in 2002 to help accredited organizationsMore information
Introduction. Definition
DIRECTIVES FOR PRIVATE AMBULATORY SURGICAL CENTRES PROVIDING AMBULATORY SURGERY: REGULATION 4(1) OF THE PRIVATE HOSPITALS AND MEDICAL CLINICS REGULATIONS [CAP 248, Rg 1] I Introduction 1 These directivesMore information
Scope and Standards for Nurse Anesthesia Practice
Scope and Standards for Nurse Anesthesia Practice Copyright 2010 222 South Prospect Ave. Park Ridge, IL 60068 www.aana.com Scope and Standards for Nurse Anesthesia Practice The AANA Scope and StandardsMore information
Guidelines for the Practice of Anesthesia in Norway
Guidelines for the Practice of Anesthesia in Norway History 1991 1st version 1994 1st revision 1998 2nd revision 2005 3rd revision on 19.03.05 by NAF (The Norwegian Society of Anesthesiology) 1 Table ofMore information
The 2015 Bangkok Global Surgery Declaration
The 2015 Bangkok Global Surgery Declaration: A Call to the Global Health Community to promote Implementation of the World Health Assembly Resolution for Surgery and Anaesthesia Care Passage of the WorldMore information
WHO Safe Surgery Checklist
WHO Safe Surgery Checklist Basia Kutryba,WHO CC Krakow; email@example.com Gerald Dziekan, Program Coordinator for WHO Safe Surgery; email@example.com Website: www.who.int/safesurgery www.safesurg.orgMore information
POSITION DESCRIPTION COLUMBUS REGIONAL HEALTHCARE SYSTEM JOB TITLE SURGICAL TECHNOLOGIST JOB CODE 0860 DEPARTMENT FLSA (Exempt/Non-Exempt) OPERATING ROOM NON-EXEMPT DEPARTMENT DIRECTOR SIGNATURE ADMINISTRATIVEMore information
healthcare associated infection 1.2
healthcare associated infection A C T I O N G U I D E 1.2 AUSTRALIAN SAFETY AND QUALITY GOALS FOR HEALTH CARE What are the goals? The Australian Safety and Quality Goals for Health Care set out some importantMore information
INFORMED CONSENT FOR SLEEVE GASTRECTOMY This informed-consent document has been prepared to help inform you about your Sleeve Gastrectomy including the risks and benefits, as well as alternative treatments.More information
The Irish Operating Department Nurses Experience of Implementation of the Surgical Safety Checklist and Timeout Safety Check
The Irish Operating Department Nurses Experience of Implementation of the Surgical Safety Checklist and Timeout Safety Check November 2010 With thanks to the all the Perioperative Nurses who completedMore information
NSQHS Standard 1 Governance
NSQHS Standard 1 Governance Definitions sheet Governance Audit Tools Definitions Contents 1. Open Disclosure Program Page 1 2. ACUTE Clinical Record Audit Tools Page 2 -----------------------------------------------------------------------------------More information
Surgical Safety Checklists and Briefings Clinician s User Guidelines
Surgical Safety Checklists and Briefings Clinician s User Guidelines 3/15/2009 Surrey Memorial Hospital Author: Keith Martinsen Before Induction Checklist Surgeon s Team Briefing Before Skin Incision ChecklistMore information
The Burgeoning Public Health Crisis: Demand Analysis and Market Opportunity for Advanced Trauma Systems in the Developing World
The Burgeoning Public Health Crisis: Demand Analysis and Market Opportunity for Advanced Trauma Systems in the Developing World Globally, the causes of mortality will experience significant shifts overMore information
Scope and Standards for Nurse Anesthesia Practice
Scope and Standards for Nurse Anesthesia Practice Copyright 2013 222 South Prospect Ave. Park Ridge, IL 60068 www.aana.com Scope and Standards for Nurse Anesthesia Practice The AANA Scope and StandardsMore information
DRAFT 7/17/07. Procedural Sedation and Rapid Sequence Intubation (RSI) Consensus Statement
Procedural Sedation and Rapid Sequence Intubation (RSI) Consensus Statement Many patients with emergency medical conditions in emergency and critical care settings frequently experience treatable pain,More information
OU Medical System Safe Procedural and Surgical Verification
OU Medical System Safe Procedural and Surgical Verification I hereby attest that I am aware of OUMS Safe Procedural and Surgical Verification process. I have received a copy of the OUMS Policy on SafeMore information
Summary: CH CONSCIOUS SEDATION It is the policy of Carondelet Health that moderate conscious sedation of patients will be undertaken with appropriate evaluation and monitoring. Effective Date: 9/4/04 RevisionMore information
May 7, 2012. Submitted Electronically
May 7, 2012 Submitted Electronically Secretary Kathleen Sebelius Department of Health and Human Services Office of the National Coordinator for Health Information Technology Attention: 2014 edition EHRMore information
Surgical Safety: Addressing the JCAHO Goals for Reducing Wrong-site, Wrong-patient, Wrong-procedure Events
Surgical Safety: Addressing the JCAHO Goals for Reducing Wrong-site, Wrong-patient, Wrong-procedure Events Sandra Ludwick Abstract Under standards set forth by the Joint Commission on Accreditation ofMore information
National Patient Safety Goals Effective January 1, 2015
National Patient Safety Goals Goal 1 Nursing are enter ccreditation Program Improve the accuracy of patient and resident identification. NPSG.01.01.01 Use at least two patient or resident identifiers whenMore information
Standards of proficiency. Operating department practitioners
Standards of proficiency Operating department practitioners Contents Foreword 1 Introduction 3 Standards of proficiency 7 Foreword We are pleased to present the Health and Care Professions Council s standardsMore information
Rise in office-based surgery and anesthesia demands vigilance over safety Advances in technology and anesthesia allow invasive
ECRI Institute Perspectives Rise in office-based surgery and anesthesia demands vigilance over safety Advances in technology and anesthesia allow invasive procedures once done only in hospitals or ambulatoryMore information
EFFECTIVE TEACHING. A Guide for Educating Healthcare Providers. Guide for Facilitators
EFFECTIVE TEACHING A Guide for Educating Healthcare Providers Guide for Facilitators Field-Test Version 2005 This document was developed by the World Health Organization and JHPIEGO. World Health OrganizationMore information
Frequently Asked Questions
The Silent Treatment: Why Safety Tools and Checklists Aren t Enough to Save Lives Frequently Asked Questions Q: Why did AACN, AORN, and VitalSmarts conduct this study? A: In 2010, the American AssociationMore information
The Newcastle upon Tyne Hospitals NHS Foundation Trust. National Early Warning Score (NEWS) Policy
The Newcastle upon Tyne Hospitals NHS Foundation Trust National Early Warning Score (NEWS) Policy Version.: 1.0 Effective From: 3 December 2014 Expiry Date: 3 December 2016 Date Ratified: 1 September 2014More information
Australian Safety and Quality Framework for Health Care
Activities for MANAGERS Australian Safety and Quality Framework for Health Care Putting the Framework into action: Getting started Contents Principle: Consumer centred Area for action: 1.1 Develop methodsMore information
STATEMENT OF PRINCIPLES: TRAUMA ANESTHESIOLOGY Introduction (Approved by the ASA House of Delegates on October 16, 2013) Trauma is a serious bodily injury or shock caused by an external source. TraumaMore information
National Patient Safety Goals Effective January 1, 2016
National Patient Safety Goals Effective January 1, 2016 Goal 1 Improve the accuracy of patient identification. NPSG.01.01.01 mbulatory Health are ccreditation Program Use at least two patient identifiersMore information
Department of Anesthesia & Perioperative Medicine 5-Year Strategic Plan FY 2012-2016. Contents
Anesthesia & Perioperative Medicine 167 Ashley Avenue, Suite 301 MSC 912 Charleston, SC 29425-9120 Tel 843 792 2322 Fax 843 792 9314 Department of Anesthesia & Perioperative Medicine 5-Year Strategic PlanMore information
Ensuring Correct Patient, Correct Site, Correct Procedure Protocol for Surgery: Review of implementation and proposals for action
Ensuring Correct Patient, Correct Site, Correct Procedure Protocol for Surgery: Review of implementation and proposals for action October 2008 Table of contents Table of contents 1. Introduction 1 2. WrongMore information
Dermatology Associates of KY, PSC Job Description
Dermatology Associates of KY, PSC Job Description Job Title: Perioperative R.N. Department: Ambulatory Surgery Center Reports To: ASC Manager FLSA Status: Non-Exempt;Hourly; Full-Time Summary ResponsibleMore information
Australian Safety and Quality Framework for Health Care
Activities for the HEALTHCARE TEAM Australian Safety and Quality Framework for Health Care Putting the Framework into action: Getting started Contents Principle: Consumer centred Areas for action: 1.2More information
High-Reliability Health Care: Getting There from Here
High-Reliability Health Care: Getting There from Here MARK R. CHASSIN and JEROD M. LOEB The Joint Commission Context: Despite serious and widespread efforts to improve the quality of health care, manyMore information
Good Practice Guidelines for Appraisal
Good Practice Guidelines for Appraisal Dr Laurence Mynors Wallis Dr David Fearnley February 2010 1 Contents Page Introduction 3 Link between appraisal and revalidation 4 Preparation for the appraisal meetingMore information
Preventing unsafe abortion
Preventing unsafe abortion Fact sheet N 388 March 2014 Key facts Around 22 million unsafe abortions are estimated to take place worldwide each year, almost all in developing countries. Deaths due to unsafeMore information
Model Legislation for Electromagnetic Fields Protection
Model Legislation for Electromagnetic Fields Protection Table of Contents WHO Library Cataloguing-in-Publication Data Model legislation for electromagnetic fields protection. 1.Electromagnetic fields -More information
The State Claims Agency Clinical Indemnity Scheme Incident Notification Requirements.
The State Claims Agency Clinical Indemnity Scheme Incident Notification Requirements. Preface The Clinical Indemnity Scheme (CIS) was established in July 2002, within the State Claims Agency (SCA), (S.I.More information
National Clinical Programme in Surgery (NCPS) Care Pathway for the Management of Day Case Laparoscopic Cholecystectomy
National Clinical Programme in Surgery (NCPS) Care Pathway for the Management of Day Case Consultant Surgeon DRAFT VERSION 0.5 090415 Table of Contents 1.0 Purpose... 3 2.0 Scope... 3 3.0 Responsibility...More information
SEPSIS: Information About Post-Operative Sepsis for Patients and Relatives WHAT IS SEPSIS? Sepsis is a life threatening condition that arises when the body s response to an infection injures its own tissuesMore information
Certified Surgical Technologist Examination Content Outline
Certified Surgical Technologist Examination Content Outline I. Perioperative Care: 105 items A. Preoperative Preparation: 29 items 1. Review surgeon s preference card. 2. Verify availability of surgeryMore information
National Quality Forum Safe Practices for Better Healthcare
National Quality Forum Safe Practices for Better Healthcare UCLA Health System advocates the National Quality Forum (NQF) endorsed safe practices.this set of safe Practices encompasses 34 practices thatMore information
PLEASE NOTE. For more information concerning the history of these regulations, please see the Table of Regulations.
PLEASE NOTE This document, prepared by the Legislative Counsel Office, is an office consolidation of this regulation, current to February 12, 2011. It is intended for information and reference purposesMore information
WRITTEN STATEMENT ON BEHALF OF THE AMERICAN ACADEMY OF PEDIATRICS PRESENTED TO THE INSTITUTE OF MEDICINE COMMITTEE ON DISABILITY IN AMERICA JANUARY 9, 2006 PAUL LIPKIN, MD, FAAP CHAIR, AAP COUNCIL ON CHILDRENMore information
Intro Who should read this document 2 Key Messages 2 Background 2
Classification: Policy Lead Author: Nathan Griffiths, Consultant Nurse Paediatric Emergency Medicine Additional author(s): N/A Authors Division: Salford Healthcare Unique ID: DDCPan04(14) Issue number:More information
Inferior Vena Cava filter and removal
Inferior Vena Cava filter and removal What is Inferior Vena Cava Filter Placement and Removal? An inferior vena cava filter placement procedure involves an interventional radiologist (a specialist doctor)More information
Policies & Procedures. I.D. Number: 1073
Policies & Procedures Title:: CENTRAL VENOUS CATHETERS INSERTION ASSISTING I.D. Number: 1073 Authorization [] Pharmacy Nursing Committee [] MAC Motion #: [x] SHR Nursing Practice Committee Source: NursingMore information
Unsafe abortion incidence and mortality
Information sheet Information sheet Unsafe abortion incidence and mortality Global and regional levels in 08 and trends during 990 08 Unsafe abortion is defined by the World Health Organization (WHO) asMore information
Measures for the Australian health system. Belinda Emms Health Care Safety and Quality Unit Australian Institute of Health and Welfare
Measures for the Australian health system Belinda Emms Health Care Safety and Quality Unit Australian Institute of Health and Welfare Two sets of indicators The National Safety and Quality Indicators PerformanceMore information
Standard 1. Governance for Safety and Quality in Health Service Organisations. Safety and Quality Improvement Guide
Standard 1 Governance for Safety and Quality in Health Service Organisations Safety and Quality Improvement Guide 1 1 1October 1 2012 ISBN: Print: 978-1-921983-27-6 Electronic: 978-1-921983-28-3 SuggestedMore information
National Quality Forum (NQF) Endorsed Set of 34 Safe Practices*
NQF Endorsed Set of Safe Practices (released 2009) 1. Leadership Structures and Systems Leadership structures and systems must be established to ensure that there is organization-wide awareness of patientMore information
To Operate or Not - Pre-operative Assessment
To Operate or Not - Pre-operative Assessment DR IVAN WARD CONSULTANT ANAESTHETIST FLINDERS MEDICAL CENTRE PULSE ANAESTHETICS About me Disclosure I am married to a Palliative Physician Risk of Death HistoricalMore information
PATIENT ASSESSMENT POLICY Page 1 of 8
Page 1 of 8 Policy applies to: All staff and allied health professionals involved in patient care delivery at Mercy Hospital (which for the purposes of this policy includes Manaaki Day Stay Facility).More information
Guideline for Medical Imaging- Patient Identification and Procedure Matching
[Optional heading here. Change font size to suit] Document Number # QH-GDL-957:2015 for Medical Imaging- Patient Identification and Procedure 1. Purpose This guideline outlines the best practice proceduresMore information
International Health Regulations
International Health Regulations World Health Organization 2008 WHO/CDS/EPR/IHR/2007.2 WHO Lyon Office for National Epidemic Preparedness and Response 58, avenue Debourg, 69007 Lyon, France Tel: +33 (0)4More information
The ASA defines anesthesiology as the practice of medicine dealing with but not limited to:
1570 Midway Pl. Menasha, WI 54952 920-720-1300 Procedure 1205- Anesthesia Lines of Business: All Purpose: This guideline describes Network Health s reimbursement of anesthesia services. Procedure: AnesthesiaMore information
Oregon State Assembly of the Association of Surgical Technologists
Support Oregon House Bill 2876 Minimum education and certification standards for surgical technologists Sponsored by the Committee on Health Care Legislative Intent: Requiring Newly-Practicing SurgicalMore information
Standard 5. Patient Identification and Procedure Matching. Safety and Quality Improvement Guide
Standard 5 Patient Identification and Procedure Matching Safety and Quality Improvement Guide 5 5 5October 5 2012 ISBN: Print: 978-1-921983-35-1 Electronic: 978-1-921983-36-8 Suggested citation: AustralianMore information
Clinical Audit Procedure for NHS-LA and CNST Casenote Audit
Clinical Audit Procedure for NHS-LA and CNST Casenote Audit NHS Litigation Authority (NHS-LA) Risk Management Standards for Acute Trusts Pilot Clinical Negligence Scheme for Trusts (CNST) Maternity ClinicalMore information
Guide to the National Safety and Quality Health Service Standards for health service organisation boards
Guide to the National Safety and Quality Health Service Standards for health service organisation boards April 2015 ISBN Print: 978-1-925224-10-8 Electronic: 978-1-925224-11-5 Suggested citation: AustralianMore information
LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER - SHREVEPORT MEDICAL RECORDS CONTENT/DOCUMENTATION Hospital Policy Manual Purpose: To define the components of the paper and electronic medical recordMore information
National Patient Safety Goals Effective January 1, 2015
National Patient Safety Goals Effective January 1, 2015 Goal 1 Improve the accuracy of resident identification. NPSG.01.01.01 Long Term are ccreditation Program Medicare/Medicaid ertification-based OptionMore information
Employment, Social policy, Health and Consumer affairs Council meeting Brussels, 1 December 2014
Council of the European Union PRESS EN COUNCIL CONCLUSIONS Brussels, 1 December 2014 Council conclusions on patient safety and quality of care, including the prevention and control of healthcare associatedMore information
Application of the concept of safe surgery checklist. Wanda Lee Ward Manager Operating Theatre Prince of Wales Hospital Hong Kong SAR
Application of the concept of safe surgery checklist Wanda Lee Ward Manager Operating Theatre Prince of Wales Hospital Hong Kong SAR Safe surgery saves lives Operating Theatres with the implementationMore information
Total hip replacement
Patient Information to be retained by patient What is a total hip replacement? In a total hip replacement both the ball (femoral or thigh bone) side of the hip joint and the socket (acetabular or pelvicMore information
NURSE CERTIFICATION PROGRAM. Self-Assessment Tool for Level 3 Certification in Pediatric Nursing
Self-Assessment Tool for Level 3 Certification in Pediatric Nursing Name of Candidate: Hospital of current employment: Introduction: A nurse Candidate who seeks to be certified as a specialist in PediatricMore information
AMERICAN BURN ASSOCIATION BURN CENTER VERIFICATION REVIEW PROGRAM Verificatoin Criterea EFFECTIVE JANUARY 1, 2015. Criterion. Level (1 or 2) Number
Criterion AMERICAN BURN ASSOCIATION BURN CENTER VERIFICATION REVIEW PROGRAM Criterion Level (1 or 2) Number Criterion BURN CENTER ADMINISTRATION 1. The burn center hospital is currently accredited by TheMore information
NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE Medical technology guidance SCOPE MAGEC system for spinal lengthening in children with early onset scoliosis 1 Technology 1.1 Description of the technologyMore information
Slide 1 Welcome to Safe Injection Practices: Protecting Yourself and Your Patients. A Bloodborne Pathogens
Slide 1 Welcome to Safe Injection Practices: Protecting Yourself and Your Patients. A Bloodborne Pathogens Training Activity. This training will provide you with important injection safety informationMore information
The WHO Surgical Safety Checklist:
The WHO Surgical Safety Checklist: to reduce harm by consistent use of best practice Provided by: National Patient Safety Agency Publication type: Quality and productivity example QIPP Evidence providesMore information
A surgical disaster: Could this happen in radiology?: A case report
A surgical disaster: Could this happen in radiology?: A case report The Cases Time Out: A WHO initiative for safer patient care By Dr D Catherine Mandel, Peter MacCallum Cancer Centre, Melbourne, VictoriaMore information
Phase 4: Evaluate Safer Medical Device(s)
NIOSH recommends that health care facilities use safer medical devices to protect workers from needlestick and other sharps injuries. Since the passage of the Needlestick Safety and Prevention Act in 2000More information
1 8 OPERATING THEATRE AND ANAESTHETIC SERVICES OVERVIEW OF OPERATING THEATRE AND ANAESTHETIC SERVICES Services in the operating theatre and anaesthetic services carry high risk. It is essential that thereMore information
Regional workshop on the development of public health control strategies on glaucoma
Summary report on the Regional workshop on the development of public health control strategies on glaucoma Cairo, Egypt 14 16 December 2009 Summary report on the Regional workshop on the development ofMore information
DATE APPROVED May Version Date Comments / Changes 1.0 May 2013 Initial Policy approved by the Clinical Integration Executive Committee (CIEC)
Page 1 of 5 APPROVED (S) REVISED / REVIEWED SUMMARY 1 Version Date Comments / Changes 1.0 Initial Policy approved by the Clinical Integration Executive Committee (CIEC) 2.0 February 2014 Approved for postingMore information
GAO ADVERSE EVENTS. Surveillance Systems for Adverse Events and Medical Errors. Testimony
GAO For Release on Delivery Expected at 10:30 a.m. Wednesday, February 9, 2000 United States General Accounting Office Testimony Before the Subcommittees on Health and Environment, and Oversight and Investigations,More information
PURPOSE SUPPORTIVE DATA To specify the parameters within which decisions regarding the withholding and/or withdrawing of life-sustaining treatment/non beneficial care and/or no initiation of cardiopulmonaryMore information
Health Service Circular
Health Service Circular Series Number: HSC 2002/009 Issue Date: 04 July 2002 Review Date: 04 July 2005 Category: Public Health Status: Action sets out a specific action on the part of the recipient withMore information
WHO Consultation on the Zero Draft Global Mental Health Action Plan 2013-2020 International Diabetes Federation (IDF) Submission
WHO Consultation on the Zero Draft Global Mental Health Action Plan 2013-2020 International Diabetes Federation (IDF) Submission The International Diabetes Federation (IDF), an umbrella organisation ofMore information
Nurse Practitioner Frequently Asked Questions
HEALTH SERVICES Nurse Practitioner Frequently Asked Questions The Frequently Asked Questions (FAQs) have been designed to increase awareness and understanding of the Nurse Practitioner role within theMore information
The Practice Standards for Medical Imaging and Radiation Therapy. Quality Management Practice Standards
The Practice Standards for Medical Imaging and Radiation Therapy Quality Management Practice Standards 2015 American Society of Radiologic Technologists. All rights reserved. Reprinting all or part ofMore information
INTRAPERITONEAL HYPERTHERMIC CHEMOTHERAPY (IPHC) FOR PERITONEAL CARCINOMATOSIS AND MALIGNANT ASCITES. INFORMATION FOR PATIENTS AND FAMILY MEMBERS Description of Treatment A major difficulty in treatingMore information
Administrative Policies and Procedures for MOH hospitals /PHC Centers. TITLE: Organization & Management Of Medication Use APPLIES TO: Hospital-wide
Administrative Policies and Procedures for MOH hospitals /PHC Centers TITLE: Organization & Management Of Medication Use APPLIES TO: Hospital-wide NO. OF PAGES: ORIGINAL DATE: REVISION DATE : السیاساتMore information
The Checklist: A Great Equalizer
The Checklist: A Great Equalizer Performance Architects are big proponents of simple responses to complex challenges. We greatly admire the elegant solution to a performance problem or opportunity. AsMore information


text:
3 people killed in tractor trailer wreck
A large highway was sent into the path of another vehicle killing the three people
By Gary Franklin
CARTERSVILLE, Ga. — CARTERSVILLE, Ga. — The state patrol has identified the three men killed in an early Wednesday morning wreck involving two tractor trailers on Interstate 75 in Bartow County.
Killed were 43-year-old George Benjamin White of Hiram, 36-year-old Jermaine Duriel Smith of Douglasville and 58-year-old Hugh Bruce Duling III of Powder Springs.
White was the driver of the northbound truck that crossed the median and struck a concrete support pillar. Smith was a passenger in White's vehicle. Duling was the driver of the southbound tractor trailer that struck a support structure in the roadway brought down by White's truck.
Full story: Victims killed in I-75 tractor trailer crash identified
- Tags
- Trauma

subset: commoncrawl


text: I see another post on this but it's a little outdated so I'm hoping there has been a recent development. Looking for a way to transmit audio from media (music, movies, audiobooks...not phone calls) to my standard bluetooth wireless device, which is not A2DP. This worked perfectly with no tweaks on my enV Touch so clearly it isn't a hardware issue, which by extension means there should be a software workaround, possibly in the form of a downloadable App. Anything that would work is cool though...registry edits, whatever, I just desperately want to listen to audiobooks at work without buying a new headset! Thanks in advance for reading/replying,


text:
If you want to ensure your credentials don't get lost once you hand them out, these wood business cards are one way to go about it. Designed by Mattison Creative for Elena Damy, the square calling cards highlight the floral and event designer's work using clever carvings.
As the graphic design studio's website explains, Elena Damy offers a one of a kind experience for her clients, which include celebrities, Fortune 500 companies and international dignitaries, so it was necessary to create credentials that reflected her unique, elegant and luxurious brand.
If you are an artisan, craftsperson or wood worker, these wood business cards could also serve as inspiration for you, if you want try your hand at making your own cards.
Creatively Carved Credentials
More Stats +/-
Subtly Textured Business Cards
Gold-Dipped Credentials
Art-Inspired Macaron Marketing
Scruffy Napkin Business Cards
Business Card Installations
Elena Damy's Wood Business Cards were Designed by Mattison Creative
- By: Alyson WyersMay 21, 2014
References: mattsoncreative & refinery29
References: mattsoncreative & refinery29


text:
Memorial Day has passed, marking the unofficial start to summer – although the actual season won't start for a month or so. The weather certainly isn't much of an indicator either!
Calendars, clocks, holidays or weather – whatever marker makes you connect with the change in seasons, all I can say is I'M READY and keep thinking of ways to encourage the warmer weather to hang around (not that my actions make that much of an impact).
One thing I do know… it's time for some laid back summertime days! Less schedule, more fireflies!
There's some catching up to do…a few things that have been on the back burner for a while; there's some cleaning up to do…a few things that need some spit and polish; and there's some changes in the air…a few things that have been waiting for the "right time". For the next couple of weeks, our goal is to simplify our "front end" and give some attention to the behind the scenes details that keep All Are Welcome running smoothly!
Our team of volunteers works very hard preparing, cooking and serving our weekly meals and we think everyone should be able to "take it easy" during the beautiful weather that's supposed to be just around the corner! We have some student groups joining us for summer service, our menu is going to be a little more basic and (hopefully) we'll be giving some of our regular staff some more free time!
We could use a few "fill-in" volunteers – even if you only have one day a month to share! Please feel free to email us at email@example.com or call our office number at 508-443-0243. Even if you've never worked in a restaurant before, we'd love to have you give our organization a try!
The JUNE menu is posted on our menu page – if you haven't eaten at All Are Welcome before, I hope you'll find something you'd like to try and join us for a community meal soon! Feel free to print and post our menu and invite friends and family to try us out, also!
Happy Summer!


text:
Watch Pill "New Clothes, New Shoes" Video, the latest video from Pill, which dropped on Monday, January 9th, 2012. Pill's horizons are broadening with each new release, and Pill "New Clothes, New Shoes" Video is no exception. It's a worthy addition to a catalogue that has seen much growth since Pill stepped foot in the rap game. We're looking forward to hearing more.
What do y'all think of this video?
Did y'all catch Pill's latest visual for Pill "It's All On Me" Video?
If you're feeling this, make sure to hit up Pill's profile page for the latest info, news, songs, and mixtapes. Don't forget to follow Pill on Twitter.


text:
Divorce Corp: Film Review
Joe Sorge's documentary examines the dysfunctional nature of America's family court system.
"The single biggest reason for divorce in this country is marriage."
That's one of the less-than-revelatory statements heard in Divorce Corp, Joe Sorge's scattershot but occasionally scarily convincing examination of the American family court system that generates some $50 billion a year. This is not surprising, considering that we're also informed that the average divorce in the U.S. costs $50,000 and that 50 percent of marriages end in divorce. Of course, the marriage rate itself could be reduced significantly if enough people could be encouraged to watch this documentary before saying "I do."
As per usual, a procession of talking heads testifies to the injustices of the system, including a private investigator who drives a Rolls-Royce thanks to his endless bounty of lucrative cases. Among those heard from are lawyers, judges, law professors, aggrieved spouses (mostly male) and such ringers as celebrity divorce lawyer Gloria Allred.
The very idea of our family court system, which generally includes no juries and no right to counsel, is called into question via a series of horrific anecdotes, the veracity of which, naturally, is hard to determine. We are informed that judges are frequently perturbed by people who choose to serve as their own attorneys, and that upon leaving the bench they frequently segue into lucrative law practices at the very firms whose cases they were previously deciding.
This is contrasted at length with the divorce system in Scandinavia, where people can apparently get unhitched without entering into gladiatorial legal combat and with their finances still intact.
Although the film, which is narrated by Dr. Drew Pinsky, makes many convincing points -- such as describing the jailing of people who fail to make their alimony or child custody payments as the modern-day equivalent of debtor's prison -- it relies too heavily on shock value rather than solid facts. While such cases as one involving a court-appointed child custody evaluator who posted lewd pictures of himself online or another featuring the horrifying video of a family court judge savagely beating his wife are luridly fascinating, they have little to do with the bigger picture.
Director: Joe Sorge
Screenwriters: James D. Scurlock, Philip Sternberg, Blake Harjes, Joe Sorge
Producers: Philip Sternberg, James D. Scurlock
Narrator: Dr. Drew Pinsky
Editor: Blake Harjes
Composers: Chris McClure, Andy Sorge
No rating, 93 minutes


text:
|Message view
|« Date » · « Thread »
|« Date » · « Thread »
|"Geir Magnusson Jr." <g...@pobox.com>
|Re: [general] Incubator graduation update
|Fri, 20 Oct 2006 16:52:22 GMT
Mark Hindess wrote: > On 20 October 2006 at 10:11, "Geir Magnusson Jr." <firstname.lastname@example.com> wrote: >> >> Mark Hindess wrote: >>> On 20 October 2006 at 9:31, Tim Ellison <firstname.lastname@example.com> wrote: >>>> FWIW: Below are the results of running RAT on a windows snapshot. >>>> For some reason it complained about lack of ASF block comments in >>>> DLLs, and proceeded to dump them to the console, so I chopped them out >>>> of the report. Looks like mainly missing block comments in emconf >>>> files. >>>> >>>> I suspect that it will be helpful to do this on an HDK snapshot, plus >>>> on a source drop (that we don't produce at present, but should IMO). >>> I'm looking at modifying the federation build to have a source drop >>> target. It looks like doing: >>> >>> svn export . target/src >>> >>> and modifying the build.xml to cope with the lack of svn files might >>> be a good start. I'll probably take a little more work but I'll get >>> something checked in so we have something to work with. >> Wait. > > I don't think I have much choice. It's more likely you'll be waiting > for me. ;-) It's not as trivial as it sounds[0] so I'm sure this > discussion will be done before I'm ready to check anything in. ;-( > >> Why not just do a tar/zip on the working_classlib and working_vm with >> a filter to keep out the generated stuff? > > This was my first thought but it didn't take long before I decided I had > to think again. I think it is much too error prone. Consider figuring > out which .so files are generated/downloaded and which are in svn. > Repeat for dll files, jar files, etc. Then keep this up to date. It'd > be a full-time job. A *real* unix hacker would walk the tree looking at .svn/entry files ;) In Perl. in less than 20 lines. > > svn export does just the right thing. It takes only the stuff you get > from svn but without the .svn files. This seems much less likely to > turn around and bite us. (Though even this isn't without issues.) Otay. geir > > Regards, > Mark. > > [0] not as trivial as I was expecting that's for sure > > > > --------------------------------------------------------------------- > Terms of use : http://incubator.apache.org/harmony/mailing.html > To unsubscribe, e-mail: email@example.com > For additional commands, e-mail: firstname.lastname@example.com > --------------------------------------------------------------------- Terms of use : http://incubator.apache.org/harmony/mailing.html To unsubscribe, e-mail: email@example.com For additional commands, e-mail: email@example.com
|View raw message


text:
Although buyers often intuitively know when they have a
great vendor, they sometimes can't tell whether a certain negative behavior is
the norm in the industry or their supplier's performance is subpar. How do you know
what is unacceptable and what you should tolerate? In this brief, we list nine signs,
beyond the typical quality issues, that your LSP may not be providing you with
the level of service you deserve. We also provide concrete steps you can take
to address each issue.


text:
Summer means lots and lots of garage sales. We're getting ready for a garage sale at our house right now. We've been sorting through lots of the girls' old stuff -- things they have outgrown or simply don't play with have all gone into the garage sale pile.
It struck me the other day, that a garage sale is a great way to teach your kids about the idea of sacrifice. Sacrifice is giving up something of yours to help someone else. If you're planning a garage sale, don't do a sneak attack on your kids' rooms. (You know, where you go in and clean it out yourself, and then look at your kids with a blank expression when they ask what happened to some toy they haven't played with in a year.)
Sit down with your kids and choose a worthy organization to which you want to donate some or all of the proceeds of your garage sale. Then, plan a time with each child to go through their rooms and sort out what will go in the garage sale. If your kids are anything like mine, they will want to hang onto just about everything. Help them to understand that their sacrifice now will help another child. Help them to decide how to price their goods.
On the day of the garage sale, let your kids help you with the sale. You can even help them set up a lemonade stand or cookie stand to earn some extra money. Be sure to post a sign telling your garage sale patrons why you are raising money (often they will pay extra for the cookies or lemonade).
When your garage sale is over, let the kids count up the money they have earned from selling their stuff. If you are donating the money, take your kids with you to drop it off, and let them present the gift. If you have chosen to use the money to buy something for an organization, let your kids go with you to pick it out.
All through the process, remind your kids that God calls us to take care of the poor. No matter your financial situation, if you live in the United States, have a car and a TV, you are one of the wealthiest people in the world. Much of the world, lives each day on what we spend on a cup of coffee.
Use these verses when you talk to your kids about sacrifice and giving:
- 2 Corinthians 9:7 -- Each man should give what he has decided in his heart to give, not reluctantly or under compulsion, for God loves a cheerful giver.
- Luke 21:1-4 -- As he looked up, Jesus saw the rich putting their gifts into the temple treasury. He also saw a poor widow put in two very small copper coins. "I tell you the truth," he said, "this poor widow has put in more than all the others. All these people gave their gifts out of their wealth; but she out of her poverty put in all she had to live on.
After you have had your garage sale and donated your money or items, ask your kids how it made them feel to help others. Ask them how they think it makes God feel when they do things like that. Be sure to let your kids know how proud you are of them that they were willing to sacrifice for others.


text:
Special Invitation for the 30th Anniversary of Le Dîner en Blanc de Paris: June 3, 2018
Chers amis, On Sunday, June 3, 2018, in one of Paris' most prestigious locations, an immense Le Dîner en Blanc will bring together some 20,000 people, half of whom are from other countries, to dine at the same table. We extend this invitation to thousands of people who, on all continents...Read More »
Thank you, Busan! See you in 2018!
To all members of Le Dîner en Blanc Busan, We were honored and thrilled that you spent your evening with us for our first edition of Dîner en Blanc Busan which was held on August 26th, 2017. Thank you for the tremendous effort you put forth to make this evening magical. The beautiful fashion, creative tables, inspiring and delicious menus and your positive attitude, helped make this experience memorable for all. Thank you to our group and table leader team: a collection of the most amazing people in our community. They helped ensure that the evening ran smoothly and that everyone got to the secret location as smoothly as possible. T...Read More »
29th Paris Edition Kept Secret Until the Very Last Minute!
Once again this year, Le Dîner en Blanc de Paris took place in utmost secrecy. The mystery surrounding the Parisian edition is the essence of this unique concept. In a world of never ending communication, it is astonishing and in some way reass...Read More »
Save the Date! The 1st Dîner en Blanc Busan on Saturday, August 26, 2017!
Chers amis, Busan, are you ready? Le Dîner en Blanc for the first time! Save the Date! Saturday, August 26, 2017! The inaugural secret affair promises an unforgettable evening of elegance, beauty, and magic as it takes over an ic...Read More »
The 28th Paris Edition Kept Secret Until the Very Last Minute!
Le Dîner en Blanc de Paris took place last night in utmost secrecy. 2016 is proving to be a trying year for Paris. With the Seine river's recent flooding, the workers' union protests, and the upcoming (and highly anticipated!) UEFA ...Read More »
|Started by
|Topic title
|Last post
|No entries found!
Read More » Most viewed questions
How many Le Dîner en Blanc events are there in the world?
Founded in 2012, Dîner en Blanc International is responsible for developing this secret posh picnic in close to 80 cities in 30 countries around the world with close 120,000 participants. The largest and most internationally recognized Le Dîner en Blanc remains the original Paris event. Launched in 1988 by François Pasquier and his close friends, Le Dîner en Blanc de Paris attracts nearly 10,000 people annually.
What are the membership and transaction fees for?
Membership and transaction fees are used to cover the inherent costs of training, support and technological services to all the organizers around the world, to enable them to organize their own event, as offered by Dîner en Blanc International. These services allow us to preserve and convey the concept's values, to sustain our corporate standards by regrouping them within a single network and, to develop technical tools. The membership offers members a number of online services that will grow in the coming years. Dîner en Blanc International is working on updating its platforms so that all participants of a Dîner en Blanc event become members. In addition, this annual fee will allow members to register for as many Dîner en Blanc events in the world as they wish.
How many Dîner en Blanc events are there in the world?
Since the founding of Dîner en Blanc International in 2012, the event has quickly spread to over 70 cities around the world, with close to 120,000 guests participating each year. The largest and most internationally recognized Dîner en Blanc remains the original Paris event. Launched nearly 30 years ago by François Pasquier and his close friends, Le Dîner en Blanc de Paris now attracts almost 10,000 people annually, with 15,000 guests attending the 25th anniversary edition in 2013.
Is it possible to organize a Dîner en Blanc in my city?
Dîner en Blanc International has established an exclusive service to facilitate the organization and management of Dîner en Blanc events around the world. This turnkey service enables interested local teams to produce Dîner en Blanc in their own city, while connecting to the international network. For more information, write to email@example.com.
How can I participate?
You can register for Le Dîner en Blanc by one of the following three methods: by being part of the Hosts or Leaders' personal network and getting invited by them (Phase 1); by knowing someone who registers during Phase 1 and asking them to sponsor you for Phase 2; or, by signing up to the waiting list and registering during Phase 3.
What are the key rules of the event?
Le Dîner en Blanc is an evening like no other. Once registration is confirmed, each guests' participation becomes mandatory, regardless of weather conditions. Participants arrive at a designated departure point with their table, chairs, and picnic materials, and then make their way to the secret location with their Table Leader by chartered bus or organized public transportation. They take all of their belongings with them at the end of the night, including leftovers and trash, and they leave the site as clean as it was upon arrival.
What must guests wear?
All guests must dress elegantly in head-to-toe white. This means no ivory, no off-white, and no beige… Originality is always encouraged, as long as it stays stylish and tasteful.
What must guests bring?
A square folding-table and two white chairs; a white picnic basket and/or bag including a gourmet meal for two, a white tablecloth and cloth-napkins, cutlery, dishware, and glassware; and a garbage bag.


text:
Dead Sea mineral water combined with Propolis, Witch Hazel and Knotgrass extracts
For oily and problem skin.
There are no reviews yet.
You must be logged in to post a review.
Visit Lana's Beauty Zone – a Premier Los Altos Skin Care and Day Spa, for highly effective skin and body care where you will receive the personal attention and professional care you deserve.
Svetlana "Lana" Tokar is a licensed Esthetician who has been practicing at leading Bay Area spas for over 20 years.
Classic European Facial The classic...
Having healthy and great-looking skin...
As you grow older, it...
Lana's Beauty Zone
398 State Street
Los Altos
(650) 947-4004
Skin Care: Facials and Waxing


text:
Greg Moormann, vegan physique competitor
Greg Moormann, vegan bodybuilder
Greg Moormann has made an impressive impact on his sport of Natural Bodybuilding with numerous podium finishes in Masters categories.
He is a Pro card holder with both the NGA and ANBF associations, which are only awarded after having reached elite standard.
- Pro Card holder with two federations
- Unbeaten in Masters Bodybuilding
- Winner in Open Category while aged over 50
Multiple tournament wins
In 2015 Greg entered the NGA Night of Champions and walked away with no less than three victories, taking first place in the Masters Physique (age 50+), first in the Novice Physique category and he also won the Open Physique Tall category.
In the same year he also won the Masters Physique category at the Florida State Natural competition. 2016 saw him enter the ABNF Florida Natural Championships where he won not only the Masters Physique 50+ but also the 40+ category. He also took first place in the Open Physique Tall category.
In May 2016 he entered NPC Suncoast Naturals and won both the 50+ and 40+ Masters Physique titles. In August 2016 he entered the Naples Sports Festival and won first place by a large margin (read more here). Later that year her took first in the ANBF Caribbean Championships (read more here).
Unsurprisingly, Greg's achievements have brought him the attention of others and he has been featured in Vegan Health & Fitness magazine three times and in Natural Muscle. In 2017 he was starting to focus on aspects of training other than competition, having won competitions by clear margins.
Finding vegan
For many years Greg was satisfied with his diet and had not seriously considered veganism. This all changed in the Summer of 2003 when he was influenced by an existing vegan. "I was dating a vegan that was a few years older than me and she was the healthiest and most beautiful human that I had ever known. This made me very curious. She never pushed her choices on me but she did ask me to read The China Study and to watch Forks Over Knives. I did so and I had thought previously that I was eating super healthy. I found out I had no option but to switch to a vegan diet. I have thrived on plant based foods and am leaner and more muscular than ever before."
The change happened overnight and Greg is now a committed vegan who achieved all of his competition successes on his current diet. He counts his Pro Cards among his greatest achievements alongside winning the titles in the Florida Natural Championships.
Fuelling committed training
Veganism is now part of his lifestyle and he is entirely committed to it. Travelling poses some challenges but nothing that can't be overcome. "I do my best to pack all the food that I will consume. I usually try to limit trips to 4 or 5 days for this reason. I will even freeze food and pack in luggage when flying, I freeze oatmeal, vegan 6 bean chili and a few other assorted meals in bulk. I always travel with my plant based protein blend for my oatmeal (pea, hemp, and pumpkin seed) as well as flax and chia seeds and hemp hearts. Sunflower butter and Mary's Gone Crackers. I will eat a lot of fruit when traveling."
When at home he eats "a lot of steel cut oats with either apples and cinnamon or blueberries (every morning)"as well as "a lot of fruit, fresh veggies, cooked and raw as well as brown rice and seitan. I have been steaming my own seitan and I love it. I also make shakes with assorted greens and fruits. I like to use beet leaves from fresh whole beats as well as spinach and kale."
The attention to diet helps fuel Greg's training, to which he is similarly committed.
"When SuzAnne Llano and I train together we usually start by riding bikes 5 miles to the gym and then working one body part per day with glutes and abs alternated every other day. We are usually in the gym for about an hour and 20 minutes. Our favorite HIIT activity follows the gym and that is riding bridge sprints over the intercoastal all up and down the east coast of South Florida. Usually after that we will play tennis for two hours. Many evenings we will go back to the tennis courts for another match."
Having worked on their knowledge, Greg and his partner SuzAnne have a great understanding of what they need to succeed and stay healthy, strong and injury-free. Greg says he is his own coach, gym and nutritionist, and he works closely with SuzAnne.
The future
They have many more goals to achieve, and are excited about them all. Greg is planning on competing in an NPC competition later in 2016, then making his Pro debut in ANBF as the year closes.
Greg also wants the two of them to become "the elder voice and role models for vegan bodybuilding."
"We want to influence and educate as many people as possible. Hopefully one day in near future we will travel together and speak and lecture. That would be my dreams and I think that they are reality." He is also working on a career in fitness modelling and an online coaching businesses. "I am a certified Health/Nutrition Coach and specialize in weight loss and energy recovery as well as nutritional consulting. I can always be reached through FB messenger, Greg Moormann NGA Pro. "
When we asked him how far he could go in competing, Greg wasn't sure. "I really don't have an answer. I have a strong desire to see where I fit in as far as national ranking for fifty year olds and that road leads to Masters nationals NPC in Pittsburgh in July of 2017."
The prospects for Greg are good and we look forward to following him. He is also pleased to be running a column in Vegan Health and Fitness Magazine, covering nutrition and readers Q&A.


text:
Flourish Team
The Flourish team is excited to introduce the Secret Pal program for 2017.
While initially the program was intended for adults only, we've decided to open it up to all interested persons. The goal of the program is to help participants get to know others on a more personal level; in a non‐threatening and non‐stressful way. Below is information about the program.
How the program will work:
Each person who participates will have two secret pals. One, who they will receive anonymous surprises from throughout the year, and one, who they provide anonymous surprises to throughout the year. The surprises can be given on special occasions such as birthdays, anniversaries, etc., when you know your pal needs extra encouragement and support, or, for no special reason at all. Participation in the program is not meant to be expensive. Participants are encouraged to give cards, make homemade items, provide meaningful scriptures, etc. Thoughtfulness, not quantity, is key.
Next Steps:
Sign‐up sheet is located in the back of the church. Complete a Secret Pal questionnaire and return to Joni Cragoe by December 4, 2016. Participants will receive their Secret Pal's information in the middle of December. While the program officially kicks off January 1, 2017, it is ok to start a little early if you want to include this holiday season! Throughout the year,
participants can give and receive anonymously! Secret Pals will be revealed in the fall of 2017.
We hope you're as excited about the program as we are and that everyone will want to participate! Please see the Flourish Team with any questions. Thank you.