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Reducing Adverse Events: 4 Areas of Focus

Publish Date: February 26, 2020



A perioperative adverse event can have substantial, far-reaching consequences. For a patient, it can lead to harm, permanent damage or even death. For staff members, an adverse event can cause emotional trauma (i.e., "second victim") and erode confidence in themselves and their teammates. It may even drive some to change jobs or careers. Surgeons can have similar emotional experiences as staff, see their reputation take a hit and possibly face legal ramifications. Facilities may also find themselves subject to a lawsuit and reputation damage.

"No one comes to work in a perioperative situation who doesn't care if they make a mistake and the patient gets hurt," says Willard Schuler, MD, a retired orthopedic surgeon. "Perioperative professionals are probably one of the most well-motivated people in the world. Unfortunately, sometimes bad things happen to good people, and a bad outcome is usually devastating to the entire perioperative team. It is imperative that we work to eliminate contributing factors to an adverse event."

Dr. Schuler, who has first-hand personal experience with a tragic outcome, identifies the following as four areas where perioperative professionals can focus to reduce the likelihood of adverse events.

  1. Freedom to speak. For years, Dr. Schuler says, The Joint Commission has stated that when a wrong-site surgery is about to occur, a majority of the time there is someone in the operating room who recognizes something is wrong but hesitates to speak.

"This hesitation can occur because someone doesn't believe it's their place to question the surgeon or they worry about saying something wrong or perceived as stupid," he says. "Some people convince themselves that a deviation from what they have come to expect during a procedure is attributable to a surgeon learning a new technique. But rarely is this the case, and it is never appropriate for a team member to remain silent when they experience doubt concerning something that could impact patient safety."

If something doesn't feel right, look right or seem right, question it, Dr. Schuler says. "Management should instill this philosophy at their facility and work so all team members — regardless of position, professional experience or years at the facility — know they should speak up when they have even an ounce of doubt about a situation that could jeopardize an outcome."

  1. Who is on the team. To help ensure a safe surgery, Dr. Schuler says perioperative professionals must know who is on their perioperative team.

"Everyone who passes through the operating room while the patient is in there should be viewed as part of the team," he says. "A technician who comes in to take a quick X-ray: on the team. A nurse who drops off a supply: on the team. A CRNA who comes in to relieve a fellow team member: on the team. Oftentimes, these individuals are not made to feel like part of the team. It is up to their coworkers to make sure this is not the case. As team members, they should feel empowered to speak up if something doesn't seem right, even if they've only been in the room a few moments."

Dr. Schuler continues, "The idea of 'who is my team' is a very important issue. It's not a hard one to understand but is critical nonetheless."

  1. Use of "standard language." Dr. Schuler is a strong advocate of the use of "standard language," sometimes referred to as "critical language."

"These are words the perioperative team has decided ahead of time that won't ever be used unless there is a situation where the team must stop everything until they figure out what's going on," he says.

The use of such language helps reduce the likelihood of a delay that causes a missed opportunity to prevent an adverse event. "Imagine a person coming into the operating room who hasn't been there from the start and sees something that appears off," Dr. Schuler says. "Now this person is trying to think of what to say or who to talk to about their concern. Instead of taking time to figure out the perfect thing to do, if critical language has been established, they know they can say something like 'garlic salt' and it will make everyone stop and immediately know something of the utmost importance is happening and must be addressed."

  1. Handoff shortcomings. A successful outcome requires several handoffs. Despite significant attention paid to the importance of handoffs for patient safety, they are often rife with problems.

"It's amazing how unstructured handoffs tend to be, even in some of the very best surgical institutions in the country," Dr. Schuler says. "Since handoffs occur so often, over time, those involved can get into such a routine that they can become easily distracted or have their mind wander and skip critical steps."

As a department, get together and identify the 8-10 pieces of information and steps required to make a good handoff, he advises. "You can pass more pieces of information and complete other steps during a handoff, but make sure you initially determine the core information and steps that must occur without fail."

Once you have this checklist, the hard work begins. Hand it out to those team members involved in the handoff, educate them on how to use the checklist and then commit to it. Monitor its usage and execution to ensure consistency.

"Ask people not involved in a case to periodically act as observers and watch the handoff process occur," Dr. Schuler says. "These observers want to make sure to document whether every core item on that checklist is covered before the handoff is completed. While staff performance may initially appear strong, as time passes and complacency develops, things can fall between the cracks."

This is where the idea of culture versus strategy sets in, he says. "Culture is the way we do things. Strategy is what administration thinks we're doing. Culture eats strategy for lunch. It's easy to change strategy. Everyone can work on strategy and it looks perfect on paper, but unless strategy becomes culture, it won't permanently affect safety and outcomes. It's a real process to change culture. That is what needs to be the objective for any change you undertake."

Learn more from Dr. Schuler in the ASC Summit workshop, “How Things Can Go Terribly Wrong When Good People Work Together and Don’t Communicate (Half-day workshop)Register Today.

Free Resources for Members

Guideline Essentials
: Improve your team’s communication and handoffs with customizable tools such as quick views, competency tools, policies and procedures templates, gap analysis tools, and more.

AORN Comprehensive Surgical Checklist: Download this customizable checklist including key safety checks as outlined in the World Health Organization (WHO) Surgical Safety Checklist and The Joint Commission Universal Protocol. 

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