Can You Pass This Patient Safety Quiz?

Keeping your patients safe is obviously a core value at your facility, yet compliance with best practices designed to avert serious complications and injuries is sometimes alarmingly low. Use this quiz as a starting point to gauge how well your staff is ready to spare your patients from unnecessary harm.

1. How long must you remain vigilant in monitoring for signs of malignant hyperthermia after surgical procedures end?

• a. 30 minutes
• b. one hour
• c. two hours
• d. three hours
• Reveal

  • Answer: b
    Even though most MH cases occur when patients are under general anesthesia, OR teams must also be vigilant in the one-hour period immediately following surgery, which the Malignant Hyperthermia Association of the United States (MHAUS) calls "a critical time" in monitoring for the rare-but-serious sudden onset condition. This includes time in the recovery room, so PACU nurses must be on alert for symptoms such as increased heart rate, rigid muscles and high fever. MHAUS also cautions that the use of trigger anesthetics and/or succinylcholine can lead to MH occurrences in procedure rooms or during office-based interventions. All ambulatory surgery centers and offices where procedures take place should stock dantrolene, the only MH antidote, and keep it close to the PACU, as well as ORs and procedure rooms.
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2. The surgeon marked the surgical site in the OR, asked the patient to confirm the location just as anesthesia was beginning and the instrument tech rolled the instruments to the side of the table before the timeout began. How many things were done wrong?

• a. none
• b. one
• c. two
• d. three
• Reveal

  • Answer: d
    The operating surgeon should mark surgical sites in pre-op, not in the OR, and communication with patients should be done before anesthesia begins. "A good final step is to not bring in the instruments until after the timeout has taken place," says Shakeel Ahmed, MD, founder and CEO of Atlas Surgical Group, a cluster of ASCs in the Midwest. "That way, it's impossible to skip the timeout and start the case."
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3. The contents of an instrument tray have been sufficiently sterilized if the blue wrap is free of punctures and the external indicator tape and indicator tag have changed color.

• a. true
• b. false
• Reveal

  • Answer: b
    Blue wrap helps to maintain a surgical tray's sterilization if it doesn't puncture. The external indicator tape and indicator tag show whether the tray has been exposed to the appropriate amount of steam, so you know it's safe to bring into the sterile field. The colors of the tape and tag vary from product to product, but they must change fully to show that the tray has achieved microbial-inactivation status. That doesn't, however, mean the contents have, says Cherokee Gonzalez, RN, BSN, director of Florida Medical Clinic, which operates nearly 50 facilities in the greater Tampa area. The chemical indicator strip inside the tray is what determines whether the instruments also received adequate amounts of steam during the autoclave cycle in order to be sterilized. Errors can happen when surgical team members assume instruments are safe to use if the external tape and tags have changed colors, says Ms. Gonzalez. The internal indicator strip must be checked as well, and must have fully changed color.
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4. During which task do most sharps injuries take place?

• a. suturing in the operating room
• b. starting IV lines in pre-op
• c. injections administered in the PACU
• d. cleaning instruments in sterile processing
• Reveal

  • Answer: a
    Nearly 42% of sticks and cuts take place in the OR, and 28% happen while suturing, according to the latest data from the Exposure Prevention Information Network. This is a big deal, says International Safety Center President and Executive Director Amber Hogan Mitchell, DrPH, MPH, CPH, because it means some needlesticks happen while providers are working in the operative site, where patient and provider exposure to bloodborne pathogens is increased. Ms. Mitchell says surgical team members should double-glove, use safety engineered devices such as retractable scalpel blades and blunt suture needles to minimize the risk of needlesticks and cuts.
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5. The risk of pressure injuries increases by _______every 30 minutes of surgery.

• a. 10%
• b. 40%
• c. 60%
• d. 100%
• Reveal

  • Answer: b
    Pressure injuries are often overlooked during same-day surgical procedures and even outpatient facilities who are on the lookout for skin injuries believe they aren't likely to happen unless the patient was on the table or in the PACU for at least three hours. "The truth, though, is that the risk for pressure injuries goes up every half-hour and can begin to happen during the first few hours of surgery," says Joyce M. Black, PhD, RN, FAAN, a professor at the College of Nursing at the University of Nebraska Medical Center in Omaha. "To prevent them, evaluate patients for vulnerabilities preoperatively and continue to monitor them in the PACU, where injuries can also occur. In the OR, pad patients' vulnerable anatomy and areas of the skin that comes into contact with positioning devices."
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6. How often do healthcare providers who divert painkillers leave some of the narcotic behind to cover their tracks, help the patient on some level and ease their conscience?

• a. always
• b. occasionally
• c. never
• Reveal

  • Answer: b
    Tampering with injectable opioids is common, particularly in the OR if anesthesia drugs are left unsecured. Diverters use the medication from a syringe, refill the syringe with saline or water, and place it back from where it was taken. This practice exposes patients to potential bloodborne pathogens such as HIV and hepatitis C, says Kimberly New, JD, BSN, RN, founder of Diversion Specialists, a consulting firm based in Chicago. As a diversion scheme progresses, however, the diverter is often no longer willing to share medication with the patient and will fail to treat the patient's pain or even administer a substitute, such as giving acetaminophen instead of oxycodone in the PACU, according to Ms. New. To prevent diversion, create awareness of the issue, design programs that hold staff accountable for the administration of all drugs, use products that dispose of and destroy unneeded medications, and audit and monitor drugs from procurement to administration or disposal.
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7. The anesthesia providers who prepare syringes for procedures at your facility designate the drug class of the medication in the syringe with colored-coded labels. Is that step sufficient to avoid an error?

• a. yes
• b. no
• Reveal

  • Answer: b
    Syringe labels must also include the complete name and concentration/dose of the drug inside, as well as a beyond-use date and time. The mislabeling of syringes, cups, basins and bowls leads to medication mix-ups that have long plagued surgical facilities, says Michael Cohen, RPh, MS, ScD, DPS, FASHP, president of the Institute for Medication Safety. In one case, a patient undergoing a breast procedure was injected with formalin, a tissue preservative, instead of the local anesthetic lidocaine 1%. Each medication was in the sterile field in unlabeled basins.
    
    Other OR mishaps have included injecting the form of thrombin that was for topical use only, a mistake that can cause intravascular clotting and death. The ISMP recommends that labels on syringes, medicine cups and basins in the sterile field should include — at a minimum — the name of the drug or solution, its strength/concentration, and the amount and volume if there are no measurement increments on the container.
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8. The use of enzymatic detergents during decontamination of ophthalmic instruments can elevate the risk for TASS and is not shown to reduce the risk of endophthalmitis.

• a. true
• b. false
• Reveal

  • Answer: a
    The Ophthalmic Instrument Cleaning and Sterilization (OICS) Task Force has released a report that highlights studies of multiple centers and their use of enzymatic detergents on ophthalmic intraocular instruments. "It was found that the rate of endophthalmitis for non-enzyme facilities was actually lower than the ones who do use it," says Carson McCafferty, MSN, RN, CNOR, CSSM, CSRN, clinical director at Eye 35 ASC in Schertz, Texas. "The report also notes that studies show there is a correlation between enzyme concentration and the severity of an inflammatory response."
    
    The OICS guidelines state that intraocular surgical instruments should be thoroughly rinsed with distilled water promptly after each use, but enzymatic detergents are unnecessary for routine decontamination. Ms. McCafferty notes that this process should be part of a facility's infection control program, which should also include a risk assessment and infection-tracking to monitor appropriate decontamination of intraocular instruments. OSM
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