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).
