UPDATES ON PATIENT SAFETY IN THE PERIOPERATIVE SETTING

PERIOPERATIVE NURSING
What is Perioperative Nursing? It is an individualized surgical nursing care in order to restore or maintain the health and the welfare of the surgical patients/ clients before, during and post surgical interventions.

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.

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.

CORE VALUES OF PERIOPERATIVE NURSING

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

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 passes off to circulator;

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.

Acts as the Circulating Nurse

A. Preoperative Phase Prepares materials needed for the operation Checks availability and completeness of the supplies, equipment and instruments necessary for the operation Assists and attends to the needs of the anesthesiologist. Assists SN in gowning Performs and records counts Admits patient to surgical suite.

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.

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.

FUNCTIONS OF A PACU NURSE

The PACU Nurse should be able to do the following : a) Attends quality circle, endorsement of patients, drugs, supplies, machines and equipment b) Attends and prioritizes the needs of the post surgical patients.

c. Gives direct 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.

d) Endorses post surgical patients to ward/ICUs properly OTHERS: Assist in the general activities in the OR such as : > acts as circulating nurse > participates in making supplies, etc,

What is Patient Safety?

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 to prevent 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 of global importance, but much work remains to be done.

WHO Vision
Every patient receives safe health care, every time, everywhere.

 Introduction:
Maintaining patient safety in the operating room is a major concern of surgeons, hospitals, and surgical facilities. Circumventing preventable complications is essential, and the pressure to avoid these complications during surgery is especially important. Traditionally, nursing and anesthesia staff have managed patient positioning and most safety issues in the operating room.

To assist operating teams in reducing the number of SENTINEL events, WHO Patient Safety- in consultation with surgeons, anesthesiologist, nurses, patient safety experts and patients around the world has identified objectives for safe surgery. The aim of this Checklist is : to reinforce accepted safety practices to foster better communication to have a team work between clinical disciplines.

Key aspects of patient safety in the operating room includes the following:
thoughtful patient positioning ocular protection proper handling of electrocautery and airway management

If performed correctly with attention to certain anatomic landmarks, preoperative positioning of the patient can prevent nerve injury and postoperative joint or muscle pain.

Surgical Safety Checklist

A. Components of the Checklist of a. Period before and after Induction

Anesthesia (nurse and anesthesiologist) b. Period before Surgical Incision (N-A-S) c. Period before Patient Leaves Operating Room (N-A-S)

Responsibility of postoperative complications 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 cosmetic surgery experience.

UNIVERSAL PROTOCOL
The fact that wrong- site , wrong- procedure and wrong- person surgeries continue to happen is disturbing, however, the good news is that they can be prevented. a. Preoperative Verification Process Purpose of this process to ensure that all relevant documents and studies are available prior to the start of the procedure, that they are reviewed they are consistent with each other, the patients expectations, and the teams understanding of the intended patient, procedure, site and any implants ( as applicable). Any missing information or discrepancies must be addressed during this time. .

b. Marking of the surgical site Purpose of this process: to identify the laterality of the surgical site using permanent pen. c. A time-out that is held immediately before the start of a procedure. Purpose of this process: to conduct a final verification of the correct patient, procedure, site, patient position and as applicable , availability of implants and special equipment/instruments this requires active communication between team members.

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

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.

Before Skin Incision

-each team member will introduce him/ herself by name and role. The team can simply confirm that everyone in the room is known to each other. The team will confirm out loud that they are performing the corrcet patient, procedure, laterality, prophylactic antibiotic has been given 60 minutes prior to the operation.

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.

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 fast paced preoperative, intaroperative and post operative preparations

Designating a single person to confirm completion of each step of the Checklist can ensure that the safety steps are not omitted in the rush to move forward with the next phase of the operation.

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 of communication: a. provide the staff access to leadership b. eliminate hierarchies between the staff c. encourage a team approach

Provide the staff access to leadership should have access to organization leadership to provide general feedback (reporting) should express concerns and frustrations 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

Encourage a Team Approach to Care

Effective teams are characterized by :trust, respect, and Collaboration Team members value familiarity over formality and watch out for each other to avoid mistakes. Such actions are the following:
a. Encourage Feedback provide staff with regular and

constructive feedback and information

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

c. Address disruptive behavior - disruptive behavior is anything that upsets the smooth flow of a situation and can compromise patient safety decrease staff satisfaction and set tone that is contrary to effective communication. d. Structured communication tools proper information is conveyed at the correct time to the correct people. > OR briefing > Debriefing > Situational Awareness

PREVENTING WRONG SITE, WRONG PROCEDURE , WRONG PERSON SURGERY

RISK FACTORS: a. Inadequate patient assessment b. Inadequate medical record review c. Exclusion of certain surgical team members in the verification process d. A culture that does not support open communication between surgical team members and fosters the idea that the surgeon is always right and cannot be questioned. e. Problems related to illegible handwriting f. Use of abbreviations related to the surgical procedure, site or laterality

PREVENTING MEDICATION ERRORS

It is important to recognize that medication management in the OR is very different from that in a typical inpatient clinical unit. In the OR, medications and solutions must be delivered aseptically to the sterile field and product packaging may be prevent 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

NATIONAL PATIENT SAFETY GOAL

The Joint Commissions Medication Management standards and National 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.

 STRATEGIES TO REDUCE THE RISK OF MEDICATION ERRORS

a. Establishing Forcing Functions > dose - limit protocol that sets limits on doses of particular medications, if a dose exceeded the limit, it would be questioned. Special permission would be required to exceed a dose. > Automatic Stop Orders/ removing certain medications b. Educating the Staff on Safe Medication Practices c. Creating a Reporting System Reporting System should not be designed to blame people but to identify system vulnerabilities that can lead to lapses in patient safety .

 AVOID POTENTIALLY DANGEROUS ABBREVIATIONS JOINT COMMISSION DO-NOT USE LIST

Do Not Use 0
U (unit) IU (International Unit)

Potential Problem
Mistaken for 0zero, the number 4 (four) or cc Mistaken for IV (intravenous) or the number 10 (ten) Mistaken for each other Period after the Q mistaken for I and the O mistaken for I Decimal point is missed

Use Instead Write unit

Write International Unit

Q.D, Q D,q.d,qd (daily) Q.O.D.,QOD,q.o.d,qod( every other day Trailing Zero (X.Omg) Lack of leading zero (.Xmg) MS MSO4 and MgSO4

Write daily Write every other day

Write X mg Write 0.X mg Write morphine sulfate Write magnesium sulfate

Can mean morphine sulfate or magnesium sulfate Confused for one another

ENSURING FIRE SAFETY

Statistics show that the most common ignition sources of surgical 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 can have severe consequences, including injury to patients and staff as well as significant damage to surgical equipment. a. fuel b. oxygen c. ignition

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

 IGNITION SOURCE: - cautery machines - fiber-optic light sources - lasers - defibrillators - halogen lights - drills - heated probes
OXYGEN SOURCES - medical grade oxygen - nitrous oxide - compressed air

 NATIONAL PATIENT SAFETY GOAL Reduce the risk of surgical fires

REQUIREMENT : Educate staff including operating licensed independent practitioners and anesthesia providers on how to control heat sources and manage fuels . PREVENTION STRATEGIES: a. Preparing Patients Appropriately > coat all exposed facial hair located near the surgical site in a water soluble jelly to make them nonflammable

>for some facial surgeries, cover the patients eyes with swabs soaked in sodium chloride.
>be aware that alcohol based skin preps are flammable and avoid poling or wicking these flammable liquid preps. >let the prepped area dry completely before covering the site with nonflammable drape. > caution patients against wearing perfume, cologne, or hairspray on the day of surgery, as these typically contain flammable components and represents potential fire hazard.

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 all equipment and document regular and preventive maintenance to ensure that the equipment is safe to operate.
TIP: When choosing new equipment ,organizations should consider its fire safety record and weigh any cost savings against potential safety issues.

d. Controlling Excess Oxygen

Surgical setting have higher- than average concentration 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

 e. Engage Staff in the Fire Prevention Process

Each member of the surgical team should play a role in preventing surgical fires. Staff should be aware of their roles.

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

 B. Anesthesiologist - stop the flow of anesthetic gases if the fire is located on the patient/drape - shut off O2 that is flowing directly to the patient - ventilate the room with air - assist with obtaining portable oxygen, suction machine and other equipment, if necessary. - determine with the authority having jurisdiction whether the emergency gas shut off values should be turned off.

 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 can be disconnected easily and safely. - save fire material for later investigation.

 D. Orderlies - ensure that hallways, evacuation routes and exits are unobstructed - 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 the fire location communicate with other OR staff as to the status of the fire and plan of action work with the anesthesiologist with regards to triage priorities for evacuation determine whether to evacuate

b. Administrative Staff

follow organization procedure for reporting a fire to the authorities keep telephone lines open

Steps towards QA program

5 S is a personal disciplinary development that promotes attitudinal change and habits. This grows from an individual level to an organizational level. a. b. c. d. e. Sort Set in order Shine Standardize Sustain ( seiri) ( seiton) simplify ( seiso) ( seiketsu) ( shitsuke)

5 s simplifies our work environment, reduces waste and no value activity while improving quality efficiency and safety.

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 the better rather than the worse making it a habit that 5s should become part of individuals life to make it successful practice

Chinese Proverb:

Sharpen the tools in order to do work effectively

THANK YOU