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8 Steps to Prevent Surgical Errors

Publish Date: 7/24/2013

Earlier this month, an article in The Boston Globe claimed surgical errors were on the rise in Massachusetts, with the report basing this claim on analysis of state data. Rather than view the data as alarming, Coleen Smith, RN, BSN, MBA, CPHQ, High Reliability Initiatives Director for the Joint Commission Center for Transforming Healthcare, says it is actually encouraging. "It means we're getting better and more transparent at essentially showing our dirty laundry. We're getting better about reporting, and we're also, as an industry, getting better at recognizing things that should be reported. Without that transparency, we will never get to the state we need to be in patient safety." 

The data also shows organizations nationwide must remain committed to examining the reasons why surgical errors occur and finding ways to reduce the number of never events. "Even if we think our processes are good, we need to be looking at ways to make them just that much better so that we reduce the points during care where the patient is put at risk," Smith says. "The patient and the patient’s safety has to always be our number one priority." 

Errors disclosed to the state since 2011 included "never events" such as anesthesia injected into the wrong leg, a guidewire left inside a patient's vein and a catheter threaded into a patient who didn't require one, with the data indicating the two most common main never events that occur are wrong-site surgery (the collective term that includes wrong site, side and patient) and retention of foreign objects. Smith provides eight steps to take to help prevent these surgical errors from occurring in your organization. 

Wrong-Site Surgery 

1. Require automation for surgery scheduling. The Universal Protocol was implemented in 2004. Why, then, are we still having wrong-site surgeries? "One of the things we figured out is that you can't just concentrate on the events that immediately surround the start of the procedure," Smith says. "Errors in the surgery process can begin way back when the surgery is first scheduled." 

Organizations that currently accept phone calls or handwritten slips of paper to schedule procedures are placing patients at greater risk than those organizations that require scheduling to be performed in a standardized manner, such as electronically or via fax, which reduces the chance of error, Smith says. 

"Handwritten requests can lead to situations where an 'R' looks like an 'L' and now your scheduler has entered the wrong side for the procedure in your scheduling system," Smith says. "Even if you discover this error, to eradicate it from throughout system once it's been entered is really difficult. Just when you think you've found all the places where that error has made its way to, there's probably one more in the system you missed and that may contribute to a wrong-site surgery." 

Smith says organizations would be wise to streamline and automate surgery scheduling and only accept electronic or fax requests. "When you accept handwritten or phone requests, you introduce more variations for how scheduling happens, and variation is in many ways the enemy of safety. With variation, it's more difficult keep track of all the rules for how to process different ways of scheduling. By limiting the way a scheduling request can enter your system and refusing to tolerate handwritten requests, you will reduce the chance for entry errors." 

2. Ensure the site mark is always visible. When the surgical site is marked — by the person performing the procedure —it needs to be marked in such a way that even after the patient is on the OR table, prepped and draped, you can still see that mark.  

"This is an area that's been a downfall for a lot of organizations," Smith says. "Either the mark washes off during the prep or they're just not used to marking it close enough to the incision site and so it doesn't show up after the patient is draped. If this becomes routine, not seeing the mark doesn't stop anybody because they're not used to seeing it." 

3. Don't rush the patient through pre-op. There is a great deal of patient documentation that needs to pass through pre-op, and organizations should not rush their review of his material.  

"The documents have to line up and all say the same thing," Smith says. "Everyone in pre-op needs to make sure they know who the patient is and everybody has to be on the same page in terms of where the site is." 

4. Make your timeout process active and robust. The timeout process should never be a passive process, Smith advises. "It's not just one person reading off the consent and waiting for a few people to nod and maybe waiting for everyone to stop their activity. It needs to be a very active, robust process that includes specific responsibilities for each of the people on the team."  

If the circulator is designated as the person who initiates the process, when it is announced that it is time for the timeout, everyone in the OR should stop what they are doing and pay attention. "Each person on that team has a role to play, whether they have some information to deliver or they have an active response to information presented to them," Smith says. "An active response versus providing passive agreement is going to ensure a much safer way for the patient to undergo that procedure." 

5. Provide education to schedulers. The process needed to ensure a correct-site surgery is complicated, Smith notes. "It's a process that can work very well but you have to understand it's a series of events. It starts with getting the information right in the scheduling area, then getting it right in pre-op and finally it's getting it right in the OR." 

As noted earlier, a mistake made during scheduling could easily jeopardize patient safety, which is why organizations would be wise to provide surgical error prevention education and training to the scheduling department. 

"I do think scheduling is overlooked a great deal of the time, and I don't think folks are very cognizant of how much potential there is for error entry in scheduling," Smith says. "That's why the Joint Commission's Targeted Solutions Tool™ on wrong-site surgery includes analysis of scheduling. It helps people look at that area in a very prescribed, defined fashion because they may not be used to really looking very hard at scheduling."  

Retained Foreign Objects 

6. Do not multitask. One of the reasons unintended retention of foreign objects occur is when the scrub person and circulating nurse are trying to perform their counts while the surgeon is still requesting instruments be passed.  

"So now the scrub tech or nurse is trying to do two things at once," Smith says. "The human brain is physically incapable of doing two things at once, which is why that count should occur in isolation of other requests for activity. If there's a really complicated case that requires moving parts while counting is occurring, having another scrub tech available to step in and assist is going to be safer for the patient." 

7. Minimize distractions. "Performing the counts is a crucial time of the surgery and therefore disruptions should be minimized, but frequently there are people that enter the OR during counting for reasons that can wait," Smith says. "Every time you distract somebody, it takes them a few minutes to reset their concentration and they're not going to be at the same point mentally they were before you distracted them." 

If a distraction occurs at crucial moments like counting of the instruments, the patient is put at greater risk, Smith notes. "It's always good to have a very clear understanding among the entire OR team that when you're doing the counts, that's all you're going to be doing. Other members of the team should be aware to suspend requests for instruments. 

8. Address requests before beginning counts. To reduce distractions, Smith says some OR teams, before beginning counts, will ask the surgeon and surgical team whether they will require any instruments during the time it will take for completion of the counts. 

"They'll ask 'what do you need on the table before I go count' so that the instrument stand next to the surgeon has the exact four things the surgeon will need in the next five minutes while the counting is going on," she says. "The scrub can still clearly see those instruments to include them in the count as well." 

Note: Keep an eye out for The Joint Commission to issue a Sentinel Event Alert for retained surgical objects before year's end. 


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