Each year, tens of millions of surgical procedures are performed
in the United States. Safely providing those procedures 100
percent of the time represents a significant challenge.
I showed the surgeon the implant boxes, who confirmed
they were the correct ones. The boxes were then opened and handed
to the scrub nurse. Shortly after the cement had set, the knee in
question didn’t look right. It was a right implant in a left
knee. Informed surgeon that the implant was wrong. Surgeon
attempted to remove the femoral component and a small piece of
the femoral condyle came away that was cemented to the femoral
component. At this point, three other surgeons scrubbed to
assist.
Several reports in the CHPSO database have pointed to the
inaccessibility of spare surgical parts or tools while a
procedure is in progress. In several cases, unique screwdrivers
or drill bits have broken, or unique-size screws went missing. In
at least one instance, the incision had to be temporarily closed
with an implant partially secured and the patient was scheduled
for re-operation to complete the procedure another day.
Julianne Morath, President/CEO of the Hospital Quality Institute
(HQI), and Rhonda Filipp, director of quality & patient safety
for CHPSO, a division of HQI, collaborated with Michael Cull of
Vanderbilt University Medical Center to develop a recent
publication for the October 2014 edition of AORN
Journal,
Strategies for Enhancing Perioperative Safety: Promoting Joy and
Meaning in the Workforce. This article focuses on the
recognition of workforce safety as a precondition of patient
safety.
To achieve their mission to continually advance the safety and
quality of anesthetic care, perioperative management, and
alleviation of pain in children, the Society for Pediatric
Anesthesia shares a concise
critical event guide for anesthesia and perioperative care
providers, called
PediCrisis.
Laterality errors, also known as side discrepancies, refer to
instances when the incorrect side is noted in one or more
sections of diagnostic reports or documentation. For example, a
radiology report that notes that a lesion is on the left side of
the body, when in reality it is on the right, would be considered
a laterality error. Uncorrected laterality errors are most
frequently associated with wrong-side surgeries, which can result
in wrong limb amputation, wrong-side arthroscopy, or resection of
wrong-side organ.
The Pennsylvania Patient Safety Authority evaluated recent
wrong site surgery reports to see which of their recommended
safety practices would have had the most impact on preventing the
events. In order from highest impact to lowest, the practices
are:
Provider verifies. All information that should
be used to support the correct patient, operation, and site,
including the patient’s or family’s verbal understanding, should
be verified by the nurse and surgeon before the patient enters
the operating room (OR).
Which is easier, driving a car or performing surgery? For those
of you who went back and reread the question above because you
thought, “I must have misread that,” you did not. I ask this
because, while many states (like California) have banned texting
or handheld cell phone use, I’m not aware of any state law
banning those activities during surgery. “Ridiculous,” you say.
Why would any state need such a law? Those of you who regularly
care for patients in the operating theater know better.
For those who’ve read Dr. Atul Gawande’s “Checklist Manifesto,”
you know that it is a very well-written book describing Dr.
Gawande’s experience in leading the creation and implementation
of the World Health Organization (WHO) Surgical Safety Checklist.
The UK National Health Service just released a ‘How to Guide’ for safer surgery and the WHO
surgical checklist. The guide includes helpful advice to
improve teamwork and communication as well as implementation of
the checklist. As stated in the guide:
“Teamwork does not emerge naturally. It is necessary to provide
time, facilities and support to help individual staff to become a
good team. A few simple team building opportunities included in
daily work can reduce cost and improve the quality of care.”
These Association of Perioperative Nurses (AORN) recommended
practices address the role of the entire surgical team
in preventing the occurrence of retained surgical items and
unretrieved device fragments, provide suggestions regarding
the role of imaging, and discuss the role of adjunct
technologies.
Patients undergoing surgical procedures are at an increased risk
of infectious complications. Surgical Site Infections (SSIs)
following operative procedures are well documented sequelae, and
can result in extended hospital stays, increased morbidity, and
increased healthcare costs. In one publication, it was estimated
that over 8 percent of the healthcare-associated infections
(HAIs) that were associated with deaths in the United States were
SSIs.
Highly Reliable Surgical Teams (HRST): Improving Teamwork and
Surgical Outcomes with Structured Briefings in a Large HMO – A
Spread Project (posted on the Institute for Healthcare
Improvement site).
This article provides an overview of a quality improvement
intervention to reduce or eliminate incorrect counts and count
discrepancies. Intervention components included educating
the perioperative staff members, standardizing count practices,
formally reviewing every reported count discrepancy with the
nursing team, and reviewing and revising the count policy
for prevention of retained surgical items.
The Surgical Care Improvement Project (SCIP) includes measures
reportable to The Joint Commission and Centers for Medicare and
Medicaid Services (CMS). Resource 1 provides assistance in
achieving organizational change.
CHPSO Patient Safety News has an article on prevention
strategies.
NoThing Left Behind®: A National Surgical Patient-Safety Project
to Prevent Retained Surgical Items
The NoThing Left
Behind web site contains information on implementing a
program to eliminate retained foreign objects, with specific
pages on sponges, needles, and instruments.
The Patient Safety Committee serves the Academy and the public by
monitoring patient safety issues and programs as they relate to
orthopaedic surgery, care, and practice. The Patient Safety
Committee interacts with governmental and private organizations
such as the Joint Commission (TJC), the World Health Organization
(WHO), and the Centers for Disease Control and Prevention (CDC)
to develop programs and materials that increase safe practices in
orthopaedics.
This report provides information on surgical and nonsurgical
procedures performed in the United States by combining two
surveys: The National Hospital Discharge Survey (NHDS) and the
National Survey of Ambulatory Surgery (NSAS).
