2013 should be a busy year for patient safety experts at hospitals and surgery centers; as quality reporting requirements continue to go into effect, facilities will be expected to ramp up compliance programs and prove their progress. Here, three patient safety experts discuss the most pressing safety topics for the next year — and what facilities can do to make sure they're up to speed. Learn more about Medline University and AORN.
1. Utilization of surgical checklists. Atul Gawande, MD, is an American surgeon and journalist whose books include Better, Complications, and — most relevant to this subject — The Checklist Manifesto. He has advocated heavily for surgical checklists, arguing that the fallibility of human memory opens the door for serious, fatal errors when surgeons rely on their training alone. According to Dr. Gawande, the use of checklists dates back to the 1930s, when airplanes were gaining more sophisticated technology in the cockpit. Though the technology was intended to improve safety, it was widely considered too complicated for a lone pilot to manage, and the rate of airplane crashes soared.
In response to the climbing error rate, pilots developed checklists to ensure that every necessary task was completed prior to take-off. The instance of crashes dropped significantly. Dr. Gawande says in The Checklist Manifesto that the same results have been proven with surgical checklists: When an OR team goes through each item one-by-one, they are less likely to miss something serious. But healthcare has been slow to adopt the tool, in part because of ingrained theories about "good medicine." Surgeons, who have gone through years of training, often believe that good medicine is up to the talents of an individual physician — not the collective, systematic effort of a checklist.
Hospitals and surgery centers will be implementing surgical checklists throughout their facilities in 2013 to avoid reductions in reimbursement. According to Kim Haines, RN, certified OR nurse and vice president of clinical resources for Medline, implementation comes down to communication and education of staff. "You have to get staff to understand the goals and have that true buy-in, where they understand the list is used to improve quality of care," she says. She adds that surgical facilities must customize checklists — available through WHO, AORN and various other organizations — to make sure they fit the flow of the facility. "A lot of facilities role-play during training to make sure everyone understands what they're supposed to do and supposed to say," she says.
2. Implementing "time outs" in the OR. Similar to the idea of the surgical checklist is the concept of the "time out," which requires OR team members to stop prior to surgery to confirm the correct side, site, patient and procedure. Ms. Haines says implementing this process, which is required by the Joint Commission and other accrediting bodies, is a matter of breaking down barriers in the operating room. "From a speaking-up standpoint, there may be intimidating between nursing staff and a physician," she says.
Make sure the leadership at your institution clearly communicates the need for a time-out and implements rules to allow anyone to speak up. Certain institutions have "red rules," which mean that any provider or team member can stop the process and point out a problem. "You need to set a very clear methodology that takes the pressure off the nurse," Ms. Haines says.
3. Increasing hand hygiene compliance. Hand hygiene compliance has been promoted in surgical facilities for years; Lisa Spruce, RN, DNP, ACNS, ACNP, ANP, CNOR, director of evidence-based perioperative practice for AORN, calls it "the one proven concept that absolutely works for preventing infections." Despite progress in this area, however, compliance in hospitals hovers around 50 percent, according to the University of Geneva Hospitals in Switzerland. "Promotion of hand hygiene is a major challenge for infection control experts," wrote Didier Pittiet, of the University of Geneva Hospitals, in an article for the CDC. "No single intervention has consistently improved compliance with hand hygiene practices." Non-compliance can be attributed to a number of factors, but experts agree that staff apathy towards the practice is a big one.
Dr. Spruce says for many hospitals, monitoring staff hand-washing practices can improve compliance. "There's been some success with just watching people and seeing how well they're doing," she says. In some cases, the sinks are monitored through a video camera, and the tapes are reviewed every week or at random to determine how well people are doing. In other cases, a staff member is assigned to walk through the hand-washing area and note staff members who fail to wash their hands. "A wonderful way to improve the process is just to have someone monitor it and then talk to the team afterwards and explain what could be done better," she says.
4. Promoting collaboration between providers. The surgical team should be trained together to make sure everyone is on the same page about OR processes, Dr. Spruce says. Historically, the OR has functioned as a hierarchy, with the surgeon on top and the other providers at his or her service. This is a problem for patient safety, because nurses and other OR providers may be hesitant to speak up if a surgeon fails to wash his hands. Staff members should be educated together, and leadership should encourage the idea that OR providers are a team.
5. Implementing a "debriefing" after surgery. Dr. Spruce recommends that OR teams conduct a "debriefing" after surgery, which means they come together and talk about the surgery that just happened. "If they have that brief conversation, they're more aware and can talk about any issues and how to prevent them," she says. "If they don't have that conversation, they can't pass that information on."
She says even though debriefings are incredibly useful in predicting future problems and reviewing old mistakes, they are one of the "least used" patient safety tools. She says for instance, the team might discuss the surgery and discover through the conversation that the patient might have a bleeding problem during recovery. That information is essential to being prepared in case complications arise, so that staff can deal with them immediately.
6. Using evidence to educate. Evidence-based practice should be the foundation from which all surgeons practice, so that patients know they are receiving care proven to work, Dr. Spruce says. Some physicians, who have had years of training and experience in the operating room, may be hesitant to adopt a surgical checklist because they feel they already know what they're doing.
But the evidence doesn't lie: In a 2008 study from the University of Toronto, published in the Archives of Surgery, researchers found that communication failures per procedure declined from 3.95 prior to list use to 1.31 after list use. Thirty-four percent of surgical briefings demonstrated the utility of the list, including identification of problems, resolution of critical knowledge gaps, decision-making and follow-up actions.
Of course, the most effective education involves holding a mirror up to the providers themselves. This is why debriefings after surgery are so important — because they point out errors that would have occurred if not for the checks and balances in place.
7. Promoting sharps safety. In March 2012, AORN released a new Sharps Safety Tool Kit, which includes new resources to help perioperative professionals reduce the risk of sharps injuries in the OR. Patient safety issues involving sharps fall into several main categories:
• Knife blades. According to Linda Groah, MSN, RN, CNOR, NEA-BC, FAAN, executive director of AORN, patient safety experts recommend nurses and surgeons implement a "safe zone," where the nurse can place the knife blade for the surgeon to pick up. This eliminates the danger of cutting the surgeon or the nurse by directly handing the knife blade from provider to provider.
• Double-gloving. Double-gloving can prevent needle sticks, as wearing two pairs of gloves is likely to prevent a needle from going straight through the glove material. Unfortunately, providers are still hesitant to double-glove because of decreased sensitivity.
• Blunt suture needles. Blunt suture needles are proven to be safe and effective for surgery, but surgeons have hesitated to embrace their use because they feel sharp needles are more appropriate. The use of blunt needles decreases the likelihood of puncturing a patient or staff member.
8. Eliminating wrong site/side/procedure surgery. In late 2012, Johns Hopkins University published a study in Surgery that totaled the incidence of wrong site/side/procedure/patient surgery over the last two decades. The numbers were staggering: Between 1990 and 2010, over 9,700 cases of retained surgical items, wrong-site surgery, wrong-patient surgery or wrong-procedure surgery occurred. Those numbers only include those cases that resulted in indemnity payments, meaning the real number (including unreported cases) is probably much higher. Study authors estimated that 4,082 of these surgical errors probably occur in the U.S. every year.
Wrong site/side surgery is entirely preventable, said Martin Makary, lead author of the Johns Hopkins study and associate professor of surgery at the hospital. Dr. Spruce says the key to preventing these errors is to educate from the top down. "Providers don't make these mistakes intentionally," she says. "It's a combination of things — system design, human factors and faulty equipment." She says it's important for hospital leaders to insist that OR teams implement a time-out, during which the providers can confirm the correct site of surgery, ask the patient to identify him or herself, and confirm the procedure with the patient's chart.
9. Retained surgical items. Dr. Spruce says Joint Commission reports are still showing the incidence of retained surgical items — and indeed, the recent Johns Hopkins found that surgeons left around 4,857 items in patients over the past two decades. In order to prevent retained surgical items, AORN recommends that the OR providers work together to count all items on the sterile field, including sponges, needles and instruments according to a list prepared for the case.
At the end of the case, those items are counted again to make sure everyone is accounted for. Dr. Spruce says this is important to think about, since a retained surgical item — or any other surgical error — can be disastrous for a patient's health. "We need to remember that the ultimate cost is to patients and family members, because we can cause them to die or be disabled for the rest of their life," she says.
10. Standardizing surgical language. If people are using different language to communicate in the OR, they may misunderstand each other, Dr. Spruce says. She recommends that all hospitals and surgical facilities work to develop a "common language." This means that if a nurse wants to stop the procedure, she knows whether to say, "Stop," or, "I want to invoke the red rule," or some other variation.
1. Utilization of surgical checklists. Atul Gawande, MD, is an American surgeon and journalist whose books include Better, Complications, and — most relevant to this subject — The Checklist Manifesto. He has advocated heavily for surgical checklists, arguing that the fallibility of human memory opens the door for serious, fatal errors when surgeons rely on their training alone. According to Dr. Gawande, the use of checklists dates back to the 1930s, when airplanes were gaining more sophisticated technology in the cockpit. Though the technology was intended to improve safety, it was widely considered too complicated for a lone pilot to manage, and the rate of airplane crashes soared.
In response to the climbing error rate, pilots developed checklists to ensure that every necessary task was completed prior to take-off. The instance of crashes dropped significantly. Dr. Gawande says in The Checklist Manifesto that the same results have been proven with surgical checklists: When an OR team goes through each item one-by-one, they are less likely to miss something serious. But healthcare has been slow to adopt the tool, in part because of ingrained theories about "good medicine." Surgeons, who have gone through years of training, often believe that good medicine is up to the talents of an individual physician — not the collective, systematic effort of a checklist.
Hospitals and surgery centers will be implementing surgical checklists throughout their facilities in 2013 to avoid reductions in reimbursement. According to Kim Haines, RN, certified OR nurse and vice president of clinical resources for Medline, implementation comes down to communication and education of staff. "You have to get staff to understand the goals and have that true buy-in, where they understand the list is used to improve quality of care," she says. She adds that surgical facilities must customize checklists — available through WHO, AORN and various other organizations — to make sure they fit the flow of the facility. "A lot of facilities role-play during training to make sure everyone understands what they're supposed to do and supposed to say," she says.
2. Implementing "time outs" in the OR. Similar to the idea of the surgical checklist is the concept of the "time out," which requires OR team members to stop prior to surgery to confirm the correct side, site, patient and procedure. Ms. Haines says implementing this process, which is required by the Joint Commission and other accrediting bodies, is a matter of breaking down barriers in the operating room. "From a speaking-up standpoint, there may be intimidating between nursing staff and a physician," she says.
Make sure the leadership at your institution clearly communicates the need for a time-out and implements rules to allow anyone to speak up. Certain institutions have "red rules," which mean that any provider or team member can stop the process and point out a problem. "You need to set a very clear methodology that takes the pressure off the nurse," Ms. Haines says.
3. Increasing hand hygiene compliance. Hand hygiene compliance has been promoted in surgical facilities for years; Lisa Spruce, RN, DNP, ACNS, ACNP, ANP, CNOR, director of evidence-based perioperative practice for AORN, calls it "the one proven concept that absolutely works for preventing infections." Despite progress in this area, however, compliance in hospitals hovers around 50 percent, according to the University of Geneva Hospitals in Switzerland. "Promotion of hand hygiene is a major challenge for infection control experts," wrote Didier Pittiet, of the University of Geneva Hospitals, in an article for the CDC. "No single intervention has consistently improved compliance with hand hygiene practices." Non-compliance can be attributed to a number of factors, but experts agree that staff apathy towards the practice is a big one.
Dr. Spruce says for many hospitals, monitoring staff hand-washing practices can improve compliance. "There's been some success with just watching people and seeing how well they're doing," she says. In some cases, the sinks are monitored through a video camera, and the tapes are reviewed every week or at random to determine how well people are doing. In other cases, a staff member is assigned to walk through the hand-washing area and note staff members who fail to wash their hands. "A wonderful way to improve the process is just to have someone monitor it and then talk to the team afterwards and explain what could be done better," she says.
4. Promoting collaboration between providers. The surgical team should be trained together to make sure everyone is on the same page about OR processes, Dr. Spruce says. Historically, the OR has functioned as a hierarchy, with the surgeon on top and the other providers at his or her service. This is a problem for patient safety, because nurses and other OR providers may be hesitant to speak up if a surgeon fails to wash his hands. Staff members should be educated together, and leadership should encourage the idea that OR providers are a team.
5. Implementing a "debriefing" after surgery. Dr. Spruce recommends that OR teams conduct a "debriefing" after surgery, which means they come together and talk about the surgery that just happened. "If they have that brief conversation, they're more aware and can talk about any issues and how to prevent them," she says. "If they don't have that conversation, they can't pass that information on."
She says even though debriefings are incredibly useful in predicting future problems and reviewing old mistakes, they are one of the "least used" patient safety tools. She says for instance, the team might discuss the surgery and discover through the conversation that the patient might have a bleeding problem during recovery. That information is essential to being prepared in case complications arise, so that staff can deal with them immediately.
6. Using evidence to educate. Evidence-based practice should be the foundation from which all surgeons practice, so that patients know they are receiving care proven to work, Dr. Spruce says. Some physicians, who have had years of training and experience in the operating room, may be hesitant to adopt a surgical checklist because they feel they already know what they're doing.
But the evidence doesn't lie: In a 2008 study from the University of Toronto, published in the Archives of Surgery, researchers found that communication failures per procedure declined from 3.95 prior to list use to 1.31 after list use. Thirty-four percent of surgical briefings demonstrated the utility of the list, including identification of problems, resolution of critical knowledge gaps, decision-making and follow-up actions.
Of course, the most effective education involves holding a mirror up to the providers themselves. This is why debriefings after surgery are so important — because they point out errors that would have occurred if not for the checks and balances in place.
7. Promoting sharps safety. In March 2012, AORN released a new Sharps Safety Tool Kit, which includes new resources to help perioperative professionals reduce the risk of sharps injuries in the OR. Patient safety issues involving sharps fall into several main categories:
• Knife blades. According to Linda Groah, MSN, RN, CNOR, NEA-BC, FAAN, executive director of AORN, patient safety experts recommend nurses and surgeons implement a "safe zone," where the nurse can place the knife blade for the surgeon to pick up. This eliminates the danger of cutting the surgeon or the nurse by directly handing the knife blade from provider to provider.
• Double-gloving. Double-gloving can prevent needle sticks, as wearing two pairs of gloves is likely to prevent a needle from going straight through the glove material. Unfortunately, providers are still hesitant to double-glove because of decreased sensitivity.
• Blunt suture needles. Blunt suture needles are proven to be safe and effective for surgery, but surgeons have hesitated to embrace their use because they feel sharp needles are more appropriate. The use of blunt needles decreases the likelihood of puncturing a patient or staff member.
8. Eliminating wrong site/side/procedure surgery. In late 2012, Johns Hopkins University published a study in Surgery that totaled the incidence of wrong site/side/procedure/patient surgery over the last two decades. The numbers were staggering: Between 1990 and 2010, over 9,700 cases of retained surgical items, wrong-site surgery, wrong-patient surgery or wrong-procedure surgery occurred. Those numbers only include those cases that resulted in indemnity payments, meaning the real number (including unreported cases) is probably much higher. Study authors estimated that 4,082 of these surgical errors probably occur in the U.S. every year.
Wrong site/side surgery is entirely preventable, said Martin Makary, lead author of the Johns Hopkins study and associate professor of surgery at the hospital. Dr. Spruce says the key to preventing these errors is to educate from the top down. "Providers don't make these mistakes intentionally," she says. "It's a combination of things — system design, human factors and faulty equipment." She says it's important for hospital leaders to insist that OR teams implement a time-out, during which the providers can confirm the correct site of surgery, ask the patient to identify him or herself, and confirm the procedure with the patient's chart.
9. Retained surgical items. Dr. Spruce says Joint Commission reports are still showing the incidence of retained surgical items — and indeed, the recent Johns Hopkins found that surgeons left around 4,857 items in patients over the past two decades. In order to prevent retained surgical items, AORN recommends that the OR providers work together to count all items on the sterile field, including sponges, needles and instruments according to a list prepared for the case.
At the end of the case, those items are counted again to make sure everyone is accounted for. Dr. Spruce says this is important to think about, since a retained surgical item — or any other surgical error — can be disastrous for a patient's health. "We need to remember that the ultimate cost is to patients and family members, because we can cause them to die or be disabled for the rest of their life," she says.
10. Standardizing surgical language. If people are using different language to communicate in the OR, they may misunderstand each other, Dr. Spruce says. She recommends that all hospitals and surgical facilities work to develop a "common language." This means that if a nurse wants to stop the procedure, she knows whether to say, "Stop," or, "I want to invoke the red rule," or some other variation.
