The OR Management Series Patient Safety in the OR 5th Edition A compilation of articles from OR Manager Editor Elizabeth Wood Editor, OR Manager Clinical Editor Judith M. Mathias, MA, RN Clinical Editor, OR Manager Contributor Cynthia Saver, MS, RN President, CLS Development Inc, Columbia, Maryland Patient Safety in the OR The OR Management Series 1 Copyright © 2014, Access Intelligence, LLC All rights reserved. No part of this book may be reproduced in any form or by any means, electronic or mechanical, including photocopying or by an information stor- age and retrieval system, without permission from the publisher. Publisher Access Intelligence, LLC 4 Choke Cherry Rd, 2nd Floor Rockville, MD 20850 Library of Congress Catalog Card Number: 2011937405 ISBN: 978-0-9914473-3-6 Printed in the USA 2 The OR Management Series Patient Safety in the OR Foreword his update of the 2011 Patient Safety in improvement approach after safety failures, the OR reflects an ever-greater emphasis and they note that organizations using this T on processes and standards aimed at im- approach have seen impressive reductions in proving outcomes. We’ve included 15 articles surgical site infections and ineffective handoffs. from 2012 and 25 from 2013, along with 5 ar- ticles published thus far in 2014. Implementation of the Affordable Care Act is shifting the emphasis to greater collaboration Every issue of OR Manager includes ar- and coordination among healthcare providers. ticles related to patient safety because almost Those themes are also explored in our patient everything done in the perioperative environ- safety articles, along with new approaches to ment is related to patient safety. We have kept age-old problems common in many ORs. readers apprised of the latest regulatory and compliance standards, recalls, safe sterilization This latest edition of Patient Safety in the OR practices, protocols for avoiding surgical site offers timely, relevant articles that can serve as infections and readmissions, preoperative and a reference for OR administrators, periopera- postoperative best practices, and advances in tive directors, and their staffs as they strive to surgical techniques, to name just some of the make their facilities and processes safer for topics we cover. their patients. Earlier this year we reported on the South Carolina Safe Care Commitment project as one example of an organization striving to meet the high reliability standards put forth by the Joint Commission in late 2013. The authors of that report (“High Reliability Health Care: Getting Elizabeth Wood There from Here”) advocate a robust process Editor, OR Manager Patient Safety in the OR The OR Management Series 3 4 The OR Management Series Patient Safety in the OR Table of Contents I. General ................................................................................................................... 7 A safer, faster way for postoperative x-rays ...............................................................................8 A steep price to pay: Fatigue compromises staff and patient safety .......................................9 Blood management: Reducing blood use reduces risks and lowers costs ...........................12 Capnography: New standard of care for sedation? .................................................................17 Early action advisable to prepare for new alarm safety standards .......................................21 Fast action, team coordination critical when surgical fires occur ..........................................25 FDA issues Unique Device Identification final rule ................................................................28 Joint Commission targets fatigue from clinicians’ extended hours .......................................30 Malignant hyperthermia: A crisis response plan .....................................................................31 Raising the bar for safety in the handling of surgical specimens ..........................................35 Safety, cost savings, simplicity back broader use of bloodless surgery ...............................38 Solid OR governance is the foundation for safety ...................................................................41 Stryker’s Neptune recall raises stakes for compliance ............................................................44 Trauma center’s mortality rate drops dramatically with use of new protocols ..................46 II. Handoffs, Briefings, Checklists, Time-outs ................................................ 49 A cure for the distracted time-out before surgery ...................................................................50 Adopting a ‘no interruption zone’ for patient safety ..............................................................53 Has your checklist effort stalled? Some advice on how to restart it .....................................56 Implementing a daily huddle protects patients, avoids delays .............................................60 Lack of surgical checklist compliance suggests need to improve implementation ............62 OR debriefings put the safety checklist ‘on steroids’ ..............................................................63 Preoperative practices overhauled after surgical checklist failure ........................................66 Team participation and planning produce quality handoffs .................................................68 Team training, checklist equal better outcomes in pilot .........................................................73 III. High Reliability ............................................................................................... 75 Rounding tool off to a good start in improving patient satisfaction .....................................76 South Carolina models high reliability standards through pilot program ..........................79 Targeted Solutions Tool helps banish communication barriers during surgery .................82 IV. Preventing Infections ..................................................................................... 85 Are you on target for meeting SSI, SCIP metrics? ....................................................................86 Curbing OR traffic: Finding ways to minimize the flow of personnel .................................88 Joint project targets prevention for colorectal surgical infections .........................................91 Have you taken steps to avoid the abuse of IUSS? ..................................................................93 Hospitals share data to prevent colorectal SSIs ........................................................................96 New AORN recommendations focus on infection prevention, patient safety ....................99 ‘Operation Zero’ targets surgical site infections .....................................................................103 Patient Safety in the OR The OR Management Series 5 Preventing SSIs: Keys to solutions lie with your front-line clinicians ................................106 Safer surgery: Six steps that aim for excellence in sterile processing .................................110 Scope storage: Don’t get hung up on a number .....................................................................113 Spore test for liquid chemical sterilant processing system ...................................................116 Taking control of implant processing practices ......................................................................118 Unprocessed tray incident prompts investigation, leads to process improvements ........121 V. Preoperative Screening .................................................................................. 123 Preoperative screening program reveals missed diagnoses and reduces mortality .........124 Safer surgery: The preoperative testing process .....................................................................126 Why are there so many unneeded preop tests?......................................................................128 VI. Retained Surgical Items ............................................................................... 129 Focus shifts to device fragments, small miscellaneous items in RSIs .................................130 VII. Wrong Patient, Wrong Surgery, Wrong Site .......................................... 133 A clearer, more robust surgical consent process ....................................................................134 ‘Just Culture’ encourages error reporting, improves patient safety ....................................135 6 The OR Management Series Patient Safety in the OR I. General Patient Safety in the OR The OR Management Series 7 A safer, faster way for postoperative x-rays ith patient safety as its primary goal, • The radiology technologist assigned to the OR the University of Michigan Health Sys- is paged and goes to the OR as soon as possible. Wtem has created a new process using • All x-ray images are digital and are sent imme- bar-coded sponges and electronic radiology or- diately to the PACS [picture archiving and com- ders to ensure no items are unintentionally left munication system], where they can be viewed. in a patient during surgery. Electronic orders • After the x-ray is read, the radiologist calls di- provide for a standardized process that not only rectly into the OR and talks with the surgeon on is safer but also saves 15 to 20 minutes in OR time. speaker phone rather than writing the result on “Having a surgical item left in the patient is paper that is faxed or hand carried to the OR. something