Updates on Patient Safety in the Perioperative Setting

8/2/2019 Updates on Patient Safety in the Perioperative Setting

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UPDATES ON PATIENT SAFETY IN THE

PERIOPERATIVE SETTING


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PERIOPERATIVE NURSING

What is Perioperative Nursing?

It is an individualized surgical nursing carein order to restore or maintain the health and

the welfare of the surgical patients/ clients

before, during and post surgical interventions.


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Objectives:

1.To help the surgical clients return as rapidly as

possible to the best physical and mental

health attainable.

2.To ease the pains/ discomfort of the surgical

patients and in case the patient did not return

to his health, he/ she should be allowed to die

in peace and with dignity.


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GOALS:

1. To provide a safe , supportive, and

comprehensive care.

2. To assist the surgeon by functioning

effectively as a member of the surgical

team.

3. To create and maintain an aseptic /sterile

environment.


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CORE VALUES OF PERIOPERATIVE NURSING


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FUNCTIONS AND RESPONSIBILITIES OF A SCRUB

NURSE

A. Pre Operative Phase Checks the card file for surgeons special needs/request

Opens sterile supplies/packs and linen

Scrubs, gowns and gloves and sets up the sterile field.

Checks for proper functioning of each instruments Performs initial counting with the circulator

Initiates TIME OUT PHASE

B. Pre-Incisional Phase

Completes the final preparation of sterile field Assists surgeon with gowning / gloving

Assists surgeon with draping and passes off suction/cautery lines


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C. Intraoperative Phase

Maintains orderly sterile field

Anticipates the surgeons needs( supplies/

equipment)

Maintains internal count of sponges, needles and

instruments

Verifies tissue specimen with surgeon, and passesoff to circulator;


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D. Closing / Post Operative Phase

Counts with CN at proper intervals

Organizes closing suture and dressings

Begins clean - up of used instruments and

equipment

Applies sterile dressings

Prepares for terminal cleaning of instruments and

non-disposable supplies Reports to charge nurse/head nurse for next

assignments.


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Acts as the Circulating Nurse

A. Preoperative Phase

Prepares materials needed for the operation

Checks availability and completeness of the

supplies, equipment and instruments necessaryfor the operation

Assists and attends to the needs of the

anesthesiologist.

Assists SN in gowning

Performs and records counts

Admits patient to surgical suite.


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B. Pre-incisional Phase

Transports patients to procedure room

Assists with the positioning of the patient

Assists anesthesiologist during induction

Performs skin prepping Assists in draping the patient,

Connects suction and cautery lines in the machine

Fixes OR lights

Regulate air conditioning

Provides foot stools as need arises.


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D. Post / Closing Phase

Counts with the SN at proper intervals Finalizes records and charges

Begins clean-up of the area/ procedure room

Applies tape on the dressing

Assists anesthesiologist in preparing patient for transfer

to PACU

Takes patient to PACU with the anesthesiologist with

the chart and endorses significant information Disposes/ endorses specimen with correct label to the

surgeon

Reports to charged / head nurse for next assignment.


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FUNCTIONS OF A PACU NURSE

The PACU Nurse should be able to do thefollowing :

a) Attends quality circle, endorsement of

patients, drugs, supplies, machines and

equipment

b) Attends and prioritizes the needs of the post

surgical patients.


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c. Givesdirect nursing care base on the ABCs:

Airway and Breathing:> assesses airways

> administers O2

> suction machines always available at bed side

Circulation:> hook to pulse oximeter

> checks O2 saturation

> monitors V/S, report to anesthesiologist

in charge for any alterations/ abnormalities> checks bleeding, assesses pain levels of the

patient.

> administers prescribed meds.


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d)Endorses post surgical patients toward/ICUs properly

OTHERS:

Assist in the general activities in the OR such as:

> acts as circulating nurse

> participates in making supplies, etc,


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According to WHO

Patient safety is the absence of

preventable harm to a patient during the

process of health care. The discipline of

patient safety is the coordinated efforts toprevent harm, caused by the process of

health care itself, from occurring to patients.

Over the past ten years, patient safety has

been increasingly recognized as an issue ofglobal importance, but much work remains

to be done.


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WHO Vision

Every patient receives safe health

care, every time, everywhere.


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Introduction:

Maintaining patient safety in the operatingroom is a major concern of surgeons,

hospitals, and surgical facilities. Circumventingpreventable complications is essential, andthe pressure to avoid these complicationsduring surgery is especially important.

Traditionally, nursing and anesthesia staff havemanaged patient positioning and most safetyissues in the operating room.


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To assist operating teams in reducing the

number of SENTINEL events, WHO PatientSafety- in consultation with surgeons,anesthesiologist, nurses, patient safetyexperts and patients around the world has

identified objectives for safe surgery. Theaim of this Checklist is :

to reinforce accepted safety practices

to foster better communication

to have a team work between clinicaldisciplines.


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Key aspects of patient safety in the

operating room includes the following:

thoughtful patient positioning

ocular protection proper handling of electrocautery

and airway management


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If performed correctly with attention

to certain anatomic landmarks,

preoperative positioning of the patient

can prevent nerve injury and

postoperative joint or muscle pain.


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Surgical Safety Checklist

A. Components of the Checklist

a. Period before and after Induction

ofAnesthesia (nurse and

anesthesiologist)

b. Period before Surgical

Incision (N-A-S)

c. Period before Patient Leaves

Operating Room (N-A-S)


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Responsibility of postoperativecomplications ultimately lies with the surgeon.

Careful attention to patient safety especially

during elective procedures is paramount.

Attention to detail in patient positioning, eye

protection, and bovie use can help avoid

unnecessary perioperative complications and

significantly improve the patient's cosmeticsurgery experience.


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UNIVERSAL PROTOCOL

The fact that wrong- site , wrongprocedure and wrongperson

surgeriescontinue to happen is disturbing, however, thegood news is that they can be prevented.

a. Preoperative Verification Process

Purpose of this process

to ensure that all relevant documents and studies areavailable prior to thestart of the procedure,

that they are reviewed

they are consistent with each other, the patients

expectations, andthe teams understanding of the intended patient,

procedure, site and any implants ( as applicable). Any missinginformation or discrepancies must be addressed during thistime.

.


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b. Marking of the surgical site

Purpose of this process:

to identify the laterality of the surgical siteusing permanent pen.

c. A time-out that is held immediately before thestart of a procedure.

Purpose of this process: -

to conduct a final verification of the correctpatient, procedure, site, patient position andas applicable , availability of implants andspecial equipment/instruments

this requires active communication betweenteam members.


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How to run the Checklist (in brief)

To implement the checklist during the surgery,

a person must be made responsible .The

checklist coordinator/ circulating nurse will do

or perform the checklist.

All steps should be checked verbally with the

appropriate team member to ensure that the

key actions have been performed


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Before induction of anesthesia

- the CC/CN will verbally review with the

anesthesiologist and patient( when

possible ) that patient identity has been

confirmed, that the procedure, site are

correct and that consent for surgery has

been given.


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Before Skin Incision

-each team member will introduce him/herself by name and role. The team cansimply confirm that everyone in the room

is known to each other. The team willconfirm out loud that they areperforming the corrcet patient,

procedure, laterality, prophylacticantibiotic has been given 60 minutesprior to the operation.


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Before leaving the Operating Room

- The team will review the operation that

was performed, completion of sponge,

instruments and labeling of any surgical

specimens obtained.


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In summary:

Having a single person lead the CHECKLIST

process is essential for its success. In the

complex setting of the OR, any of the steps

may be overlooked during the fastpacedpreoperative, intaroperative and post

operative preparations


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Designating a single person to

confirm completion of each step of

the Checklist can ensure that thesafety steps are not omitted in the

rush to move forward with the next

phase of the operation.


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IMPROVING COMMUNICATION AND

AVOIDING DISTRACTIONS

Creating a Culture of Communication

Effective communication is:

a. complete

b. accurate

c. timely

d. unambiguous/precise

e. clearly understood

Some ways to establish and support a culture ofcommunication:

a. provide the staff access to leadership

b. eliminate hierarchies between the staff

c. encourage a team approach


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Provide the staff access to leadership

should have access to organization leadership to provide generalfeedback(reporting)

shouldexpress concerns andfrustrations and celebrate success

Eliminating Hierarchy

Team leaders must work to eliminate hierarchies within the area, the

Team Leaders must sets tone for team interactions. He/she works to

flatten hierarchies by using first names, engage in the care process and

incorporate suggestions and expertise of individual team members into

the plans.

Need to overcome the educational experiences of the staff

Need to be trained to think as individuals rather than as a team

Consider teaching communication skills to all health care providers

Provide team training


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Encourage a Team Approach to Care

Effective teams are characterized by :trust, respect,and Collaboration

Team members value familiarity over formality andwatch out for each other to avoid mistakes. Such

actions are the following:

a.Encourage Feedback provide staff with regular andconstructive feedback and information

b. Provide team training training can mold a group intoa unified entity that can face problems, identify issues andwork together to care for a patient


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c.Address disruptive behavior - disruptivebehavior is anything that upsets the smoothflow of a situation and can compromise patientsafety decrease staff satisfaction and set tonethat is

contrary to effective communication.

d.Structured communication toolsproperinformation is conveyed

at the correct time to the correct

people. > OR briefing

> Debriefing

> Situational Awareness


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PREVENTING WRONG SITE, WRONGPROCEDURE

, WRONGPERSON SURGERY

RISK FACTORS:

a. Inadequate patient assessment

b. Inadequate medical record review

c. Exclusion of certain surgical team members inthe verification process

d. A culture that does not support open

communication between surgical team members

and fosters the idea that the surgeon is alwaysright and cannot be questioned.

e. Problems related to illegible handwriting

f. Use of abbreviations related to the surgical

procedure, site or laterality


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PREVENTING MEDICATION ERRORS It is important to recognize that medication management in

the OR is very different from that in a typical inpatientclinical unit.

In the OR, medications and solutions must be deliveredaseptically to the sterile field and product packaging may beprevent delivering a medication aseptically in its original

container. Inconsistent and illegible labels or a lack of any labels can

contribute to medication errors.

Safe Medication Practices in the OR

a. Right patient

b. Right medication

c. Right dose

d. Right time

e. Right route


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NATIONAL PATIENT SAFETY GOAL

The Joint Commissions Medication Management standards andNational Patient Safety Goals require organizations to implement

safe medication practices.

Deliver Medications Safely

Label all medications, medication containers( syringes, medicine

cups/glass/basins) or other solutions on and off the sterile field.

Medications are dispensed safely

Verify Medication Labels( all medications in the OR should be

labeled at all times. Any medications lacking an identification labels

should be discarded

Identify patient and confirm medication allergies. ( before a

medication is administered, the perioperative staff should verify

the patients identity.


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STRATEGIES TO REDUCE THE RISK OF MEDICATIONERRORS

a. Establishing Forcing Functions> dose - limit protocol that sets limits on doses of

particular

medications, if a dose exceeded the limit, it wouldbe questioned.

Special permission would be required to exceed adose.

> Automatic Stop Orders/ removing certainmedications

b. Educating the Staff on Safe Medication Practices

c. Creating a Reporting System

Reporting Systemshould not be designed to blamepeople butto identify system vulnerabilities that can leadto lapses in patient safety .


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AVOID POTENTIALLY DANGEROUS ABBREVIATIONS

JOINT COMMISSION DO-NOT USE LIST

Do Not Use 0 Potential Problem Use Instead

U (unit) Mistaken for 0zero, thenumber 4 (four) or cc

Write unit

IU (International Unit) Mistaken for IV(intravenous) or the

number 10 (ten)

Write International Unit

Q.D, Q D,q.d,qd (daily)

Q.O.D.,QOD,q.o.d,qod(every other day

Mistaken for each other

Period after the Q

mistaken for I and the

O mistaken for I

Write daily

Write every other day

Trailing Zero (X.Omg)

Lack of leading zero(.Xmg)

Decimal point is missed Write X mg

Write 0.X mg

MS

MSO4 and MgSO4

Can mean morphinesulfate or magnesium

sulfate

Confused for one another

Write morphine sulfate

Write magnesium

sulfate


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ENSURING FIRE SAFETY

Statistics show that the most common ignition sources ofsurgical fires are :

electro surgery and

lasers, and the most common locations of surgical fires are

in the airway and on the head/face.

THE FIRE TRIANGLE

Although surgical fires do not happen often, they canhave severe consequences, including injury to patients and

staff as well as significant damage to surgical equipment.a. fuel

b. oxygen

c. ignition


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Components of the Fire Triangle

FUEL SOURCE: - alcohol base prepping agents- linens

- dressings

- ointments

- surgical equipment and supplies

- topical anesthesia sprays

- povidone iodine solutions

- synthetic sutures

- human tissue

- gastrointestinal or bladders gases- tracheal tubes/ breathing circuits

- body hair

- blood pressure cuffs


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IGNITION SOURCE: - cautery machines- fiber-optic light sources

- lasers- defibrillators

- halogen lights

- drills

- heated probes

OXYGEN SOURCES - medical grade oxygen

- nitrous oxide

- compressed air


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NATIONAL PATIENT SAFETY GOAL

Reduce the risk of surgical fires

REQUIREMENT : Educate staff including operating licensedindependent practitioners and anesthesia providers on howto control heat sources and manage fuels .

PREVENTION STRATEGIES:

a. Preparing Patients Appropriately

> coat all exposed facial hair located near the surgical site

ina water soluble jelly to make them nonflammable


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>for some facial surgeries, cover the patients eyeswith swabs soaked in sodium chloride.

>be aware that alcoholbased skin preps areflammable and avoid poling or wicking theseflammable liquid preps.

>let the prepped area dry completely before coveringthe site with nonflammable drape.

> caution patients against wearing perfume, cologne,

or hairspray on the day of surgery, as thesetypically contain flammable components andrepresents potential fire hazard.


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b. Using Equipment Safely

ex: ESU : -should be in a standby mode

-should be activated only when the active

electrode tip is in view

- active electrode tip should be kept clean to

minimize the likelihood of sparking or burning of

tissue debris.

c. Maintaining Equipment

Faulty equipment can wreak havoc during surgery. All equipment that is used in the OR should be calibrated and

inspected frequently.

The organization should have a maintenance plan for allequipment and document regular and preventive maintenance toensure that the equipment is safe to operate.

TIP: When choosing new equipment ,organizations should considerits fire safety record and weigh any cost savings against potentialsafety issues.


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d. Controlling Excess Oxygen

Surgical setting have higher- than averageconcentration of oxygen. Nearly 75% of flash fires

are related to oxygen rich atmosphere.

TIP:

use pulse oximeter to monitor a patient

use O2 only when necessary

check O2 connections to make sure they are

leak free


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e. Engage Staff in the FirePrevention

Process

Each member of the surgical team

should play a role in preventing surgicalfires. Staff should be aware of their

roles.


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Responsibilities of the Surgical Team during a Fire

Emergency

WITH IN THE OR

A. Primary Surgeon

- primary surgeon: quickly remove any burning material

from the

patient

- work to extinguish the fire

- control any bleeding- complete the surgical procedure as quickly as possible

- prepare to help evacuate the patient, if necessary


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B. Anesthesiologist

- stop the flow of anesthetic gases if the fire islocated on

the patient/drape

- shut off O2 that is flowing directly to thepatient

- ventilate the room with air

- assist with obtaining portable oxygen, suctionmachine

and other equipment, if necessary.

- determine with the authority havingjurisdiction whether the emergency gas shut offvalues should be turned off.


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C. Scrub Nurse and Circulating Nurse

- remain with, protect, and reassure the patient- identify a fire free escape route

- help remove burning material from the patient

and place it on the floor to extinguish

- help extinguish the fire, if the fire is small.

- disconnect any electrical equipment that canbe disconnected easily and safely.

- save fire material for later investigation.


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D. Orderlies

- ensure that hallways, evacuation routes and exits areunobstructed

- help obtain addition supplies as necessary.

OUTSIDE THE OR

a. Charge nurse or Clinical Leader designated to handle OR fire

response.

determine the number of people in the area. instruct all visitors to exit the area in an orderly fashion

note the time the fire began

communicate with the fire chief or safety officer regarding thefire location

communicate with other OR staff as to the status of the fire andplan of action

work with the anesthesiologist with regards to triage prioritiesfor evacuation

determine whether to evacuate


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b. Administrative Staff

follow organization procedure for reporting a

fire to the authorities

keep telephone lines open


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Steps towards QA program

5 S is a personal disciplinary development thatpromotes attitudinal change and habits. This growsfrom an individual level to an organizational level.

a. Sort ( seiri)

b. Set in order ( seiton) simplifyc. Shine ( seiso)

d. Standardize ( seiketsu)

e. Sustain ( shitsuke)

5 s simplifies our work environment, reduces wasteand no value activity while improving quality efficiencyand safety.


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5 s in the workplace

How to make 5s work in the workplace:

continual practice is most important

setting the momentum

understand the philosophy

look at the deficiency of the current situation

build the courage and mindset that change for thebetter rather than the worse

making it a habit that 5s should become part of

individuals life to make it successful practice


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Chinese Proverb:

Sharpen the tools inorder to do work

effectively


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THANK YOU

Updates on Patient Safety in the Perioperative Setting

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