Linda Homan, BSN, CIC, clinical and professional services for Ecolab, Jan Davidson, RN, MSN, the AORN perioperative education specialist focusing on ambulatory surgery centers, and Anne Dean of The ADA Group share 10 top patient safety issues that will impact healthcare facilities in 2012.
1. Hand hygiene. Hand hygiene tops the list of patient safety issues year after year, and 2012 is no exception. Ms. Davidson and Ms. Homan agree that despite a continued push for adequate hand hygiene, providers still fail to sanitize properly when they're in a hurry. Ms. Homan says ASC administrators can improve hand hygiene among their staff by tracking compliance with technology. "Staff should be practicing hand hygiene when they're moving from clean to dirty areas," she says. "We now have technology that lets you track compliance as people enter and exit a room, and you can track that information to the individual level, by geographic location and by physician versus other healthcare providers."
Outside of new technology, the old standards work too: Providers should be washing their hands for as long as it takes to sing the "happy birthday" song twice, as well as washing all the way up to the elbow with alcohol-based disinfectant (or soap and water with an alcohol-based disinfectant if hands have been grossly contaminated). Ms. Davidson recommends using a "secret shopper", or one unidentified person in the surgery center who monitors hand hygiene compliance. "If you have raw data on hand-washing that staff can see, that's a little more meaningful than just saying, 'You never wash your hands,'" she says.
2. Safe surgery checklists. CMS is expecting surgery centers to use a safe surgical checklist for the entirety of 2012, with compliance beginning on Jan. 1. Ms. Dean says because of this mandate, safe surgery checklists should be top on every ASC administrator's safety priority list. She says the use of safe surgical checklists sometimes meets with resistance from nurses, physicians and other providers, who believe that the information on the safe surgical checklist is already documented elsewhere in the patient's chart.
Ms. Dean encourages administrators to remind providers that the safe surgical checklist is a requirement — and that having all the information on one page can improve patient care. "When they're doing a chart audit, it will be easier to use the safe surgical checklist than to thumb through different pieces of paper," she says. Surgery centers can download sample safe surgery checklists at the World Health Organization website, AORN website or at SafeSurg.org.
3. Patient selection criteria. Ms. Dean says Medicare has emphasized the importance of patient selection criteria in surgery centers in 2012. Because surgery centers are not appropriate for all types of patients — including those with morbid obesity, cardiac problems and other co-morbidities — surgery centers must employ a strict patient selection criteria to prevent hospital transfers.
Ms. Dean says in the benchmarking study she conducted with her 36 ASC clients, she found that hospital transfers were frequently tied to problems that should have been identified by an ASC scheduler or consulting physician. She says she has increasingly seen surgery centers admit patients of ASA classes III and IV, compared to the recommended classes of I and II. She says ASCs should develop a strict patient selection criteria with physicians and anesthesiologists and then share that "checklist" with schedulers, OR supervisors and pre-op coordinators to make sure the ASC suffers no unnecessary hospital transfers.
4. Surface disinfection. Ms. Davidson says providers may skimp on surface disinfection because "if it's not visibly dirty to us, we forget to wipe it down." She says providers may be in a hurry and forget required steps such as wiping the blood pressure cuff down between patients. These are issues that centers are cited for in accreditation and OSHA surveys, so it's critical to remind surgery center staff of the standard.
Ms. Homan says technology can assist surgery centers in promoting environmental hygiene: Monitoring products such as fluorescent markers can identify whether an OR suite has been cleaned properly after surgery. She says surgery center administrators should also invest in tools that are proven to clean surfaces more effectively, such as microfiber, which is better at picking up organic material on surfaces but takes no more time to use.
5. Wrong-site procedures. Ms. Dean says while the incidence of wrong-site procedures has decreased between 2011 and 2010, the process for preventing wrong-site surgery still needs to improve. She says the process should start at scheduling. "When the physician scheduler calls our ASC scheduler, they should communicate about the site of the procedure," she says. Then, when the patient's history arrives at the surgery center prior to the day of surgery, the staff member putting the chart together checks the history against the information from scheduling.
Ms. Dean says the patient should never be in the operating room when the surgeon discovers the information on the consent form doesn't match the information on the H&P. "That's not the time to be having that conversation," she says. "That conversation needs to be stopped at the front desk and should definitely go no further than pre-op." She says the pre-op coordinator should be involved in talking to the OR supervisor and the scheduling coordinator to determine the correct site of surgery before the patient enters the OR.
6. Dependence on safety tools. Ms. Davidson says a major issue for the 2012 is the "lack of critical thinking skills" among OR providers. "By that, I mean we have checklists before the patient goes into surgery — to make sure they've removed their dentures, used the bathroom and emptied their bladders — and I think sometimes we become so dependent on these tools that we forget to think for ourselves," she says.
With the introduction of mandated safe surgical checklists, Ms. Davidson says providers should be even more aware of the need to evaluate patients based on experience and instinct. "If an elderly patient is having surgery that will require intubation, do we think ahead about positioning devices that may be needed for anesthesia to safely place the endotracheal tube without compromising the patient's cervical spine?" she says. She says these critical thinking skills depend on ongoing staff education. AT the beginning of every shift, a good practice would be for the surgery center staff to go over any "near misses" that happened the day before, such as a medication error that was caught before it reached the patient.
7. Burns. Ms. Dean says she has seen a recent increase in the number of burns in her client surgery centers, with one center reporting three burns in the last two years. She says all the burns were electrosurgical-related, and the problem should be a "quick fix" for most surgery centers. She says surgery centers should re-train physicians not to set hot holsters on the patient's drapes.
Physicians and other providers should also understand that inadequate contact between the grounding pad and the skin can cause fires. The grounding pad should be placed so that the entire surface of the pad is in uniform contact with the pad site, and providers should avoid any tenting or gaps where parts of the pad are not in contact with the pad site. The pad site should also be free from lotions, oils or other fluids. "Our center's physicians had a lot of in-service education and competency evaluation, and we also did a study to evaluate the degree to which the patient got wet with irrigating solutions during the surgery," she says.
8. Distractions in the operating room. Distractions in the operating room can result in numerous issues that jeopardize patient safety, such as wrong-site procedures or misuse of medication. Ms. Dean says she frequently sees providers using their cell phones, watching movies or simply failing to pay attention during crucial moments like time-outs. In one busy multi-specialty surgery center, she noticed that when the circulator announced the time-out, the rest of the staff — the surgeon, the scrub tech, the radiology tech and the equipment tech — kept performing their individual tasks without stopping for the time-out.
She encouraged the circulator to raise her voice and really insist on the time-out because of event's importance in promoting patient safety. "As the circulator, you are the patient's advocate, and you are also protecting the surgeon by ensuring that you're performing surgery on the correct site and that nobody is going to end up hurt," she says.
9. Housekeeping. ASC administrators should look over their current housekeeping services in 2012 to make sure housekeeping staff are compliant with ASC standards, according to Ms. Dean. She says some housekeeping staff members may not be aware that they have to do things like clean the wheels on the OR equipment by rolling them through a germicidal solution. They may have even been told not to touch the equipment, which Ms. Dean calls a "huge, huge problem." She says administrators should also completely eliminate the practice of home laundering from their facilities. "Some surgery centers still have staff wearing scrubs home and laundering them at home," she says.
She says OSHA standards dictate that housekeepers must be proficient in English so that they can understand the instructions on solutions and equipment. "According to OSHA, housekeeping staff have to be able to read and speak English so they can read the labels and protect themselves," she says. She says she also sees housekeeping staff failing to change water in their buckets when they move from room to room — a big problem, since failing to change water can spread bacteria.
10. Properly trained staff. Ms. Dean says Medicare has expressed concern over the prevalence of improperly trained OR staff in the surgery center industry. She said she did not believe the problem was that serious until she began to see unqualified staff in the surgery centers she worked with. "In a surgery center I no longer work with, they hired as an OR supervisor a girl who is a nurse practitioner but who is not OR-trained," she says. "She's been in some ORs, but she doesn't have the experience to be an operating room supervisor." She said in this case, she would expect 3-5 years of OR experience for an OR supervisor.
She said she has also seen surgery centers hire housekeeping staff with no healthcare experience in order to save money. "They might have cleaned offices, but they've never cleaned operating rooms before, and nobody is training them," she says. She says if an ASC is planning to hire housekeeping staff with no healthcare experience, the staff needs to undergo extensive training before they can clean the ASC. She says ASC leaders should also conduct audits by coming to the surgery center after-hours and observing whether the cleaning staff follows protocols.
Related Articles on Infection Control:
Johns Hopkins Turns to Color-Coded Scrubs to Fight Infections in the OR
WHO Surgery Checklist May Yield Varying Results Depending on Level of Compliance
Patient Education Tool: Patient's Guide to Hand Hygiene Flyer
1. Hand hygiene. Hand hygiene tops the list of patient safety issues year after year, and 2012 is no exception. Ms. Davidson and Ms. Homan agree that despite a continued push for adequate hand hygiene, providers still fail to sanitize properly when they're in a hurry. Ms. Homan says ASC administrators can improve hand hygiene among their staff by tracking compliance with technology. "Staff should be practicing hand hygiene when they're moving from clean to dirty areas," she says. "We now have technology that lets you track compliance as people enter and exit a room, and you can track that information to the individual level, by geographic location and by physician versus other healthcare providers."
Outside of new technology, the old standards work too: Providers should be washing their hands for as long as it takes to sing the "happy birthday" song twice, as well as washing all the way up to the elbow with alcohol-based disinfectant (or soap and water with an alcohol-based disinfectant if hands have been grossly contaminated). Ms. Davidson recommends using a "secret shopper", or one unidentified person in the surgery center who monitors hand hygiene compliance. "If you have raw data on hand-washing that staff can see, that's a little more meaningful than just saying, 'You never wash your hands,'" she says.
2. Safe surgery checklists. CMS is expecting surgery centers to use a safe surgical checklist for the entirety of 2012, with compliance beginning on Jan. 1. Ms. Dean says because of this mandate, safe surgery checklists should be top on every ASC administrator's safety priority list. She says the use of safe surgical checklists sometimes meets with resistance from nurses, physicians and other providers, who believe that the information on the safe surgical checklist is already documented elsewhere in the patient's chart.
Ms. Dean encourages administrators to remind providers that the safe surgical checklist is a requirement — and that having all the information on one page can improve patient care. "When they're doing a chart audit, it will be easier to use the safe surgical checklist than to thumb through different pieces of paper," she says. Surgery centers can download sample safe surgery checklists at the World Health Organization website, AORN website or at SafeSurg.org.
3. Patient selection criteria. Ms. Dean says Medicare has emphasized the importance of patient selection criteria in surgery centers in 2012. Because surgery centers are not appropriate for all types of patients — including those with morbid obesity, cardiac problems and other co-morbidities — surgery centers must employ a strict patient selection criteria to prevent hospital transfers.
Ms. Dean says in the benchmarking study she conducted with her 36 ASC clients, she found that hospital transfers were frequently tied to problems that should have been identified by an ASC scheduler or consulting physician. She says she has increasingly seen surgery centers admit patients of ASA classes III and IV, compared to the recommended classes of I and II. She says ASCs should develop a strict patient selection criteria with physicians and anesthesiologists and then share that "checklist" with schedulers, OR supervisors and pre-op coordinators to make sure the ASC suffers no unnecessary hospital transfers.
4. Surface disinfection. Ms. Davidson says providers may skimp on surface disinfection because "if it's not visibly dirty to us, we forget to wipe it down." She says providers may be in a hurry and forget required steps such as wiping the blood pressure cuff down between patients. These are issues that centers are cited for in accreditation and OSHA surveys, so it's critical to remind surgery center staff of the standard.
Ms. Homan says technology can assist surgery centers in promoting environmental hygiene: Monitoring products such as fluorescent markers can identify whether an OR suite has been cleaned properly after surgery. She says surgery center administrators should also invest in tools that are proven to clean surfaces more effectively, such as microfiber, which is better at picking up organic material on surfaces but takes no more time to use.
5. Wrong-site procedures. Ms. Dean says while the incidence of wrong-site procedures has decreased between 2011 and 2010, the process for preventing wrong-site surgery still needs to improve. She says the process should start at scheduling. "When the physician scheduler calls our ASC scheduler, they should communicate about the site of the procedure," she says. Then, when the patient's history arrives at the surgery center prior to the day of surgery, the staff member putting the chart together checks the history against the information from scheduling.
Ms. Dean says the patient should never be in the operating room when the surgeon discovers the information on the consent form doesn't match the information on the H&P. "That's not the time to be having that conversation," she says. "That conversation needs to be stopped at the front desk and should definitely go no further than pre-op." She says the pre-op coordinator should be involved in talking to the OR supervisor and the scheduling coordinator to determine the correct site of surgery before the patient enters the OR.
6. Dependence on safety tools. Ms. Davidson says a major issue for the 2012 is the "lack of critical thinking skills" among OR providers. "By that, I mean we have checklists before the patient goes into surgery — to make sure they've removed their dentures, used the bathroom and emptied their bladders — and I think sometimes we become so dependent on these tools that we forget to think for ourselves," she says.
With the introduction of mandated safe surgical checklists, Ms. Davidson says providers should be even more aware of the need to evaluate patients based on experience and instinct. "If an elderly patient is having surgery that will require intubation, do we think ahead about positioning devices that may be needed for anesthesia to safely place the endotracheal tube without compromising the patient's cervical spine?" she says. She says these critical thinking skills depend on ongoing staff education. AT the beginning of every shift, a good practice would be for the surgery center staff to go over any "near misses" that happened the day before, such as a medication error that was caught before it reached the patient.
7. Burns. Ms. Dean says she has seen a recent increase in the number of burns in her client surgery centers, with one center reporting three burns in the last two years. She says all the burns were electrosurgical-related, and the problem should be a "quick fix" for most surgery centers. She says surgery centers should re-train physicians not to set hot holsters on the patient's drapes.
Physicians and other providers should also understand that inadequate contact between the grounding pad and the skin can cause fires. The grounding pad should be placed so that the entire surface of the pad is in uniform contact with the pad site, and providers should avoid any tenting or gaps where parts of the pad are not in contact with the pad site. The pad site should also be free from lotions, oils or other fluids. "Our center's physicians had a lot of in-service education and competency evaluation, and we also did a study to evaluate the degree to which the patient got wet with irrigating solutions during the surgery," she says.
8. Distractions in the operating room. Distractions in the operating room can result in numerous issues that jeopardize patient safety, such as wrong-site procedures or misuse of medication. Ms. Dean says she frequently sees providers using their cell phones, watching movies or simply failing to pay attention during crucial moments like time-outs. In one busy multi-specialty surgery center, she noticed that when the circulator announced the time-out, the rest of the staff — the surgeon, the scrub tech, the radiology tech and the equipment tech — kept performing their individual tasks without stopping for the time-out.
She encouraged the circulator to raise her voice and really insist on the time-out because of event's importance in promoting patient safety. "As the circulator, you are the patient's advocate, and you are also protecting the surgeon by ensuring that you're performing surgery on the correct site and that nobody is going to end up hurt," she says.
9. Housekeeping. ASC administrators should look over their current housekeeping services in 2012 to make sure housekeeping staff are compliant with ASC standards, according to Ms. Dean. She says some housekeeping staff members may not be aware that they have to do things like clean the wheels on the OR equipment by rolling them through a germicidal solution. They may have even been told not to touch the equipment, which Ms. Dean calls a "huge, huge problem." She says administrators should also completely eliminate the practice of home laundering from their facilities. "Some surgery centers still have staff wearing scrubs home and laundering them at home," she says.
She says OSHA standards dictate that housekeepers must be proficient in English so that they can understand the instructions on solutions and equipment. "According to OSHA, housekeeping staff have to be able to read and speak English so they can read the labels and protect themselves," she says. She says she also sees housekeeping staff failing to change water in their buckets when they move from room to room — a big problem, since failing to change water can spread bacteria.
10. Properly trained staff. Ms. Dean says Medicare has expressed concern over the prevalence of improperly trained OR staff in the surgery center industry. She said she did not believe the problem was that serious until she began to see unqualified staff in the surgery centers she worked with. "In a surgery center I no longer work with, they hired as an OR supervisor a girl who is a nurse practitioner but who is not OR-trained," she says. "She's been in some ORs, but she doesn't have the experience to be an operating room supervisor." She said in this case, she would expect 3-5 years of OR experience for an OR supervisor.
She said she has also seen surgery centers hire housekeeping staff with no healthcare experience in order to save money. "They might have cleaned offices, but they've never cleaned operating rooms before, and nobody is training them," she says. She says if an ASC is planning to hire housekeeping staff with no healthcare experience, the staff needs to undergo extensive training before they can clean the ASC. She says ASC leaders should also conduct audits by coming to the surgery center after-hours and observing whether the cleaning staff follows protocols.
Related Articles on Infection Control:
Johns Hopkins Turns to Color-Coded Scrubs to Fight Infections in the OR
WHO Surgery Checklist May Yield Varying Results Depending on Level of Compliance
Patient Education Tool: Patient's Guide to Hand Hygiene Flyer