Patient Safety

NOTHING FOR GRANTED The commitment to patient safety starts before the patient walks through the door, says Carol Fairchild, RN, BS, CASC, and continues with at least 3 hard stops along the way. A chart that’s been flagged doesn’t get through the OR door.

Carol Fairchild, RN, BS, CASC, director of the Crane Center for Ambulatory Surgery in Pittsfield, Mass., says her facility’s commitment to patient safety required a significant investment — including bringing a trainer on site — but one that’s paying off in time, money, peace of mind and this year’s OR Excellence Award for Patient Safety.

The safety trainer was the centerpiece of her facility’s heightened efforts to safeguard its patients. After the initial training session, every department and every staff member had 3 days of training. “We had to commit a lot of hours and a lot of money up front while at the same time trying to run a busy surgery center,” says Ms. Fairchild. “But we definitely felt it was important.”

How important? Occasionally, she and her staff are reminded. “We had a near-miss a couple of months ago,” she says. “But our training prevented us from making an error that day. Later, we thought back to how we used to do things, and we realized that if we didn’t have these [new] processes in place, we would have made that mistake.” And incurred who-knows-how-much in potential liability? “When something like that happens, it emphasizes to the whole staff the importance of all the redundant things they do to ensure safety,” says Ms. Fairchild.

A large component of the training, which was done through LifeWings, was about empowering people. “It starts at the pre-surgical acceptance level,” says Ms. Fairchild. “The [staff] at the front desk know that if they see a patient drinking water in the waiting room, they can tell someone.”

Physicians are key
Not that the total commitment — and the expenditures that would be required — were an easy sell. “A lot of people felt it was too time-consuming and that all these steps were unnecessary,” says Ms. Fairchild. Once the board made the final decision to go all in, everything started with the surgeons. “We made sure we had the physicians on board before we started training the staff,” says Ms. Fairchild. “And we all know they’re 100% committed to the effort, which is important because it makes the staff more committed.”

Once upon a time in a land far away
How far was far? On Cave Creek, they say!
What was this place in that nook or that cranny?
Well, they work on bones — from young ones to grannies.
No tummies or eyeballs or noses they fix.
They like hammers and drills and drivers and picks.
With so many bones from shoulder to toe,
we like to make sure we’re all in the know.
You sign a consent but we’ll ask lots of times,
“Which site is correct?” This info is prime.
With all of our rules and things that we do,
you will not proceed without your tattoo.
First you’ll be shaved with clippers and tape.
Once you’re asleep we’ll prep and we’ll drape.
We’ll have to make sure before he can start,
we have the right patient, we have the right part.
It’s called the time out. Before all is dark,
we’ll look for the Sharpie’s obtrusive black mark!
He’ll make his incision and we’ve done our due.
To all double-check the safety for you.
When you awaken with bandage in place,
it may be Coban or stocking or Ace.
An ode to sharpies, we’ll shout it en masse!
For without its dark mark, you shall not pass.
That’s the way it is done at TOSCA, my friend.
From safety at start to a comfortable end.

— Portia King, RN

Once patients reach the OR, surgeons lead the facility’s time outs, but that’s not until numerous other safety-ensuring protocols have been strictly followed.

“It all starts before the patient even walks in the door to the center,” says Ms. Fairchild. “The procedure is verified by the scheduler and we use a universal protocol form that starts in pre-op and focuses on patient identification, procedure verification and site marking. If sites are unmarkable, we use an armband, which must be applied by the surgeon. The rationale is that surgeons mark sites, so if an alternate method is used, they need to apply the alternate method, too.”

The process also includes making sure all needed implants and antibiotics are available, and checking patient ID. “Everything is documented and it’s a very, very rigid procedure,” says Ms. Fairchild. “It creates at least 3 hard stops, where someone’s going, hold on, stop the boat, do I have everything I need?”

If anything is missing — if a patient needs to have an H&P updated, if a consent still needs to be signed, or if a pre-op nurse has any concerns — a color-coded flag is affixed to the chart. No flagged charts are permitted through the OR door, and flags can only be removed by the people who put them there.

Only then are patients allowed into the OR, where one last robust physician-led time out is carried out before the first cut is made.

“Fortunately, we never had a big mistake before we started this,” says Ms. Fairchild. “There’s nothing more devastating than a wrong site or wrong procedure. But one of the big benchmarks for errors is near-misses, and we’ve definitely had a reduction in those.”

Along with empowering employees, promoting communication and implementing fail-safe procedures, the Crane Center has also taken several other steps to guard the safety of both patients and staff, including:

• Switching to laryngeal wands that don’t require the use of a laser. “When you’re lasering off lesions, the risk of fire is sky-high,” says Ms. Fairchild. “With the new wands, the risk of fire is minimal and they’re much safer for patients’ airways. They cost a little more, but we think they’re worth it.”
• Installing smoke evacuators in every OR. “Our staff members weren’t used to using them all the time, but we did some research and showed them that when things are vaporized, a big concern is the stuff that’s in the smoke, not just the smoke itself.”
• Using ALARA (as low as reasonably achievable) as the standard for radiation exposure. “It’s 30% of what the government allows,” says Ms. Fairchild. “We also have ceiling-mounted lead shielding that protects the whole body, and we provide portable shields, in addition to lead aprons.”
• Investing in a low-dose C-arm.
• Certifying all nurses in advanced cardiac life support (ACLS) and pediatric advanced life support (PALS).

Catching on
One of the advantages of a top-to-bottom safety initiative is that it becomes contagious. People start looking for other ways to improve safety and efficiency.

“In addition to standard emergency manuals, our anesthesia and nursing staff worked together to assemble an emergency manual that specifies treatment for common and rare surgical complications,” says Ms. Fairchild. “Our crew resource team audited 441 case carts and found that 30% were incorrect. Many had errors because pick cards were incorrect. Now we’re not pulling things we don’t need, and nurses don’t have to run around getting things at the last minute. The team also redesigned the packs we use for pain management. They found we were throwing out half of the stuff in the packs. We do 50 or more pain cases a week, so that saved a lot of money.”

Small mistakes are bound to happen, but the idea is to make sure they don’t get repeated.

“We also now have a new methodology for changing preference cards,” says Ms. Fairchild. “We hung up red pens in the ORs, so if someone finds an error, the correction can be made right there in red ink that’s easy to see. Then the cards go back to the case coordinator to make the correction in the system.”

At Crane, if it promotes safety, it’s likely to be viewed as a good investment.

“People were saying that the wheels on our case carts were hard to push,” says Ms. Fairchild. “So we did some research and found an alternative. It cost about $3,000 for new wheels, but if they’re easier to push — and they save somebody from a back injury — that’s a good investment for us.”

— Jim Burger