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Preventing surgical errors - Your role (Part 2)

Publish Date: 4/17/2013
If you don't know your role in preventing surgical errors, you are more likely to jeopardize a patient's safety. Gaining clarity of your function and understanding your responsibilities leads to better practices for protecting patients and preventing surgical errors.

In this two-part series, we discuss the role, function and responsibilities for the prevention of surgical errors for four perioperative professional positions: administrator, educator, circulator and OR manager. Part one of the series, which can be found by clicking here, discussed the roles of administrator and educator.

In this column, part two, Carrie Jensen, RN, CNOR, clinical manager at Franciscan Health System's St. Clare Hospital in Lakewood, Wash., discusses the role of OR managers play in helping prevent surgical errors while Kathleen Overly, BSN, CNOR, staff nurse at St. Clare Hospital discusses the responsibilities of the circulator.

OR manager

The following are five critical ways Jensen says OR managers help prevent surgical errors.

1. Ensure compliance with standards and policies. "First and foremost, we make sure the staff follows the rules and regulations, such as AORN standards and the Joint Commission's National Patient Safety Goals NPSGs," she says. "In addition, we have our own internal policies for surgical safety checklists and other safety-related policies. We don't want to see any deviation from our policies and checklists."

2. Serve as a role model. "Every day I'm here, I serve as a role model for the staff," Jensen says. "I think that's very important. It is important to always emulate what you want to see in return from your staff. Our core values at FHS — reverence, integrity, compassion and excellence —are very important and represent the fundamental foundation of how we serve our patients and fellow co-workers. Our team is built solidly around these values."

3. Provide support. Jensen says OR managers need to support their staff in a number of ways, including ensuring staff members' receive proper training concerning policies and they understand the expectations of their role in providing safe, quality care and protecting patients.

"I observe my team at work, and we conduct regular audits to make sure we're all following policies and everybody is moving forward in the right direction," she says. "I'm also the staff's backup and support if they have issues and concerns with anything from doing the safety checklist to somebody not complying with our standards, be it a surgeon or another staff member. I'm their support to come in and make things right; to make sure everything we do is for the patient."

Jensen also notes that she is the first person staff members will come to when somebody needs to be held accountable. "I will have the first conversation with somebody who is maybe not doing things exactly the way we want — and the patient needs," she says. "If I can't get resolution, then I go up the chain until we get resolution because safety is a 'non-negotiable' for us."

St. Clare Hospital has an anonymous reporting system, and as OR manager, Jensen receives the reports. "I investigate these reports and look to see whether there are process errors or learning opportunities for staff and if there is anything we should change to improve our care."

4. Empower staff. "Here at Franciscan, we have a 'culture of safety,'" Jensen says. "For me, that's empowering my staff to be able to, at any time, stop anything that's happening — whether it's signing a permit, the beginning of a procedure or even in the middle of a procedure — because of a need for clarification concerning anything that could jeopardize safety. The culture of safety is about giving them that ability — the permission to speak up and stop whatever is happening until everybody is on the same page — and to do that without fearing blame or retaliation."

5. Work to find ways to improve safety. To provide the safest care possible, Jensen says the OR team needs to constantly work at improving their care and exploring different ways to learn about protecting patients rather than just remaining complacent.

"We held safety summit this past October," she says. "It was a two-hour summit on the surgical safety checklist and other issues surrounding safety. We had 100 percent participation by our staff and all of our providers, and everyone signed agreements stating they will follow our safety guidelines and rules and pay attention to the safety of our patients. Our new hire employees also attend a safety summit within 60 days of their hire date. There are plans to make this an organization-wide annual event. We also have site-based monthly safety council meetings addressing safety issues, reviewing audits, discussion around practice issues and following up on the feedback from participants at the safety summit."

Part of improving safe care is to learn from mistakes, not ignore them. "When a mistake is made, we always like to review with the staff what happened and learn from it," Jensen says. "We want to find something positive out of something bad. It's about educating others so that mistake doesn't happen again."


Overly identifies six important ways circulators help prevent surgical errors.

1. Protect the patient at all times. "I've always looked at it as I'm the patient's eyes, ears and voice while they're with me and when they're asleep," Overly says. "I feel like everything I do —from when I first make contact with the patient until when I let them go into recovery — is all about making sure nothing happens to them that's not supposed to happen."

2. Ensure proper preparation. Prior to a procedure, Overly says she works to ensure patients understand the surgical process and she verifies that the members of the surgical team have completed their responsibilities.

"Concerning my patients, we check to make sure their consent is correct and it matches the doctor's plan and their H&P; that the appropriate site is marked; allergies have been checked; orders have been checked; and implants have been checked to make sure everything needed for their procedure is in the facility so there will be no unnecessary delays. That's the short list," she says. "We make sure the doctor has done his or her part with the orders, consent and H&P; that anesthesia has its consent signed and everything is done before we go back to the OR.

"We also make sure autoclaves are working properly every morning by checking them with chemical and biological indicators," Overly adds.

3. Assess the OR. Once the OR is opened, Overly says another safety verification process takes place.

"We verify the implants and we count all of the instruments, both audibly and visibly," she says. "We make sure equipment has been properly maintained and we know how to use the equipment that will be required for the procedure. We make sure everything relating to safety and quality is in the room, from fire extinguishers, count bags for our sponges to any positioning equipment that will provide more comfort for the patient. We check the expiration date and package integrity for anything that's opened. We even check lighting and suction. Sometimes even the simplest things are super important for patient safety. Each member of your team needs to possess an 'all-over' surgical safety consciousness."

4. Perform the surgical safety checklist. Once the patient is draped, the OR team performs its surgical safety checklist.

"This is where we, as a whole team, stop what we're doing and everyone focuses on the patient and each other," Overly says. "We introduce each other, go over our patient identifiers and make sure that, even with drapes on, the site is visibly marked for everybody to see in the room. The surgeon goes through his or her extensive list; then anesthesia; then the nursing team and technologists go over what is important and any patient concerns."

The surgical safety checklist at St. Clare Hospital is on a large laminated poster that is a few feet high and wide. "We actually bring that fairly close to the field so it can be read by the surgeon as he or she leads it," Overly says. "Each participating member reads their portion; nothing is ever done by memory."

5. Remain focused during the surgery. "As the procedure progresses, we're also eyes and ears for everybody in the room," Overly says. "We're looking for breaches in sterile techniques; looking for anything people might be missing. We're facilitating what anesthesia needs, what the surgeons need. We're opening things; we're managing the room; we're taking calls; we do a lot of different things to help the team in the room take care of our patient. In our culture of safety, as a circulator nurse, it's my responsibility to my patient to always have a strong voice in the room."

6. Continue error prevention efforts into recovery. At the end of each case, Overly says the OR team conducts a de-briefing before the surgeon leaves the room. "We go over things such as the exact procedure that was performed, what went well, what didn't go well, equipment issues that needed to be addressed, what specimens were taken, review our counts and make sure they were correct."

Overly says she then conducts a skin assessment and completes components of her post-procedure plan of care before patients are moved into recovery.

"For recovery, my role is to provide as pertinent and detailed of a report as it pertains to that patient moving forward to the nurse I'm handing the patient off to," she says. "I need to always be in that role of making sure safety is the first priority and that everybody has the information they need to continue that process of protecting the patient."

Guidelines for Perioperative Practice


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