TIME FOR TIME OUT Staff and surgeons at Barnet Dulaney Perkins Eye Center confirm the correct patient, eye, procedure and lens implant before every procedure.

When asked about what she does to ensure patients are protected during every aspect of surgery, Elizabeth Wein, MPS, RN, CNOR, NEA-BC, executive director of surgical services at Saint Clare's Health System in Denville, N.J., starts to share. Five minutes later, a pause. "That's one long sentence," she says with a laugh. "I guess everything we do is related to patient safety in one way or another." That probably sounds a lot like your facility. There's no doubt you already place extreme importance on protecting those in your care. The following solutions will just make it easier to do.

1. Pre-printed medication labels
Pre-printed medication labels improve the efficiency and accuracy of medication administration, says Ms. Wein. "You don't face issues with illegible penmanship," she explains. "Even when staff or anesthesia providers print drug information, they don't always print clearly," she says. "The important details aren't always evident."

Imelda Kelly, RN, CRNO, director of regulatory compliance at Barnet Dulaney Perkins Eye Center in Phoenix, Ariz., says pre-printed medication labels encourage her CRNAs to follow safe medication administration protocols — they only have to note their initials, and the date and time syringes are filled — during a packed day of high-volume cataracts that could see them preparing multiple syringes for up to 40 patients. "If they had to write all that information over and over again," says Ms. Kelly, "I don't think we'd get what we wanted in terms of compliance."

Beverly Kirchner, RN, BSN, CNOR, CASC, president of Genesee Associates in Highland Village, Texas, says staff at the surgery centers she manages pre-print labels for medications listed on pre-op orders. They then check the label against the drug, stick the label on a syringe, draw the medication and re-check the filled syringe against the order. Finally, they note their initials and the date on the label to confirm the syringe's contents match what was ordered. The process holds staff accountable for the drugs they administer. "Not only have we given them tools to avoid mistakes," says Ms. Kirchner, "but they have the obligation to check their own work so they catch their own errors."

FILL IN THE BLANKS Pre-printed labels save time and improve the accuracy of medication administration.

2. Time-out reminders
Ms. Wein says time-out reminder signs hang in each OR at the Saint Clare's Health System. The signs state that the whole surgical team must agree on the correct patient, procedure, clinical decisions, consent and lab tests.

Whether you use time-out reminders posted on walls, printed on instrument sleeves or embossed on towels, or simply ingrain the pre-op pause into the culture of your facility, surgical teams have to focus on confirming surgery's essentials before every procedure, with each member of the team playing an active role in the discussion.

For that reason, there's no such thing as same-day cataracts at Barnet Dulaney Perkins Eye Center, even though patients are discharged soon after procedures end. Patients don't present for surgery until pre-op testing is complete, needed implants are on hand and paperwork is filled in correctly.

"We're all about preparation," says Ms. Kelly. "We do everything in advance so there are no surprises on the day of surgery."

Multi-layered patient safety checks are the benefits of all that pre-planning. Even though Ms. Kelly's facility works off EMRs, her staff generates paperwork that spells out the procedure, the eye to be operated on, the lens implant, the surgeon — all of which is noted on a day-of-surgery template that's hung next to the patient in pre-op and in the procedure room.

The consent that was signed in the surgeon's office also lies on the patient's chest during the pre-op time out. Staff and the surgeon work off both it and the template to confirm the correct patient, eye, implant and procedure. It's the advanced level of confirmation that ensures every member of the care team is informed and on the same page, which is especially important during high-volume, repetitive specialties where things move quickly and details can be missed.

3. Active patient warming
Active warming methods — forced-air devices, fluid warming, thermal pads on the OR table, conductive warming blankets — go beyond patient comfort. Maintaining normothermia helps prevent shivering, increased blood pressure, surgical site infections and decreased drug metabolism — important issues that jeopardize patient health and stall recoveries.

But don't ignore the physiological and psychological benefits of a warmed blanket, says Ms. Wein. Her patients are wrapped in warmed blankets as they exit the OR, and her staff keeps forced-air warming blankets in pre-op and the PACU to ensure patients remain normo-thermic and comfortable throughout the duration of their stay.

4. Permanent site marking
Patients who present for cataract surgery at Barnet Dulaney Perkins Eye Center point to the correct eye during the pre-op assessment and a nurse places a sticker dot above it. The surgeon then uses a surgical marking pen to sign his initials on the dot during his pre-surgical assessment. Ms. Kelly notes that the dot is not placed on the patient's scrub cap, which can shift or be removed; it's placed directly on the patient's skin, so there's no question about which eye it should sit above.

As they do in most facilities, surgeons in the Saint Clare's Health System sign their initials at the surgical site with an indelible marker when patients are in the pre-op holding area. The hospital health system also stocks sterile markers that can be used to make additional marks in the OR, as might be necessary during breast surgery.

Ms. Kirchner says her facilities use single-use markers specifically designed for site marking so the ink doesn't rub off during skin prepping. She says the markers' purple ink can be difficult to see on patients with dark skin, so in those instances her staff triple checks the surgical site to ensure the surgeon's initials are still present.

Cherry Maloney, RN, MBA, CSPM, the central sterile manager at the Callahan Eye Hospital in Birmingham, Ala., says laterality risk is a major concern at her high-volume ophthalmology facility. Surgeons are required to mark their initials above the correct eye with sterile markers and place a wristband on the side of the correct eye.

"The banded wrist is kept outside of the drape in case the initials are covered after draping," explains Ms. Maloney. "Patients do not enter the OR until this pre-time-out verification has been completed. We have had great success with no wrong-site surgeries, largely due to this process."

5. Pre-op shower kits
Asking patients to bathe or wipe with antiseptic agents in an effort to reduce skin flora before surgery makes good intuitive sense, even if the practice has not yet been directly linked to a reduction in surgical site infection risk.

Patients at Meriter Hospital in Madison, Wisc., are instructed to use 2% chlorhexidine-impregnated wipes at home in the days leading up to surgery, thanks to a recent suggestion by the hospital's infection preventionist. "We remind them to do it during pre-procedure phone calls, ask them if they complied during assessments in pre-op and wipe them down again before they go back to the OR," says Christina Jackson, MSN, RN, CNOR, the hospital's director of perioperative services.

Guaranteeing that patients comply with pre-op cleaning instructions while at home is of course impossible, but automated text message reminders offered by some take-home kits or simple phone call reminders from your staff improve the likelihood that they'll wash or wipe as indicated. In the end, simple is better, says Ms. Kirchner. "If you provide a product with clear instructions, patients tend to follow them," she says. "We found that using an easy-to-understand kit works better for compliancy."

ON THE SPOT Surgeons must sign their initials at the surgical site in ink that won't fade during skin prepping.

6. Retained object detection
The Joint Commission has labeled retained objects a "never event" and items left behind make for good headlines in the local paper. More importantly, says Ms. Jackson, preventing the never event from occurring is an important aspect of patient safety that demands your attention.

"We all know this is an area prone to breakdown, as easy as it is to count the number of items used during surgery," says Ms. Jackson. "We're all human and make mistakes."

Her staff is currently trialing 2 types of retained object detection devices as a result of a risk assessment conducted by the hospital's patient safety officer. The first involves radio frequency identification. Each sponge comes affixed with an RFID tag, which is detected when a staff member waves a wand over the patient after closing. The second system includes sponges marked with unique bar codes. Staff scan the removed sponges into the system, which tracks specific sponges and keeps an overall count.

Both systems aim to take potential human error out of the equation. "We don't want to take away from our current counting process," says Ms. Jackson. "We want something that will augment the efforts of our staff. If there is human error, we want to rely on the technology as a safety net."

Routine focus
Ms. Wein believes it's important to remind staff about the importance of remaining vigilant about patient safety. "Protecting patients is like anything else — you can't go on autopilot because you do it every day," she says. "Every patient is unique, and you have to pay close attention during each and every case."