By Don Sadler
Surgery is an inherently dangerous undertaking. This is easy to forget sometimes when you consider the incredible advances that have been made recently in surgical technology and techniques.
But each year, thousands of mistakes and complications occur in the OR that result in longer and costlier hospital stays for patients – and in worst-case scenarios, end up costing patients their lives.
Therefore, it’s critical for all OR personnel to remain continually focused on what they can do to improve patient safety.
A Risky Endeavor
“By its very nature, surgery is a risky endeavor,” says Alex Haynes, MD, MPH, Associate Director for the Safe Surgery Program at Ariadne Labs and Assistant Professor of Surgery at Harvard Medical School.
Haynes points out that extensive research has demonstrated that the lifesaving and transformative potential of surgery significantly improves when the surgical team focuses on communication, teamwork, OR preparation and safety procedures.
“Many surgical risks revolve around communication and teamwork among OR personnel,” he says. “Everyone in the OR needs to be on the same page regarding the patient’s condition, medications and the intent of the surgical procedure.”
“Historically, the surgeon has been viewed as the most important person in the OR, but the reality is that surgery is the ultimate team undertaking,” Haynes adds. “Everyone on the team — including surgeons, anesthesiologists, perioperative nurses and surgical techs — is vital to ensuring a safe surgical outcome.”
Haynes was a member of the team that created the Safe Surgery Checklist that was adopted by the World Health Organization in 2008 as the global standard of care. Adoption of this checklist, which is used in an estimated 50 million operations performed annually worldwide, has been shown to reduce surgical complications and mortality by up to 47 percent.
In 2015, Ariadne Labs launched a national effort to bring the Safe Surgery Checklist to every hospital in the U.S. Ariadne Labs is also developing specialized safety checklists for ambulatory surgery centers, emergency rooms and OR crises. “These build on the Safe Surgery Checklist,” says Haynes.
SSI, RSI and Other Risks
There is a wide range of patient safety risks in the OR. These include surgical site infections (SSIs), retained surgical items (RSIs), wrong-site surgeries, improper medication labeling and administration, and improper patient positioning and lifting.
Research has shown that SSIs are by far the most common OR safety risk, with an occurrence rate of between one percent and three percent per procedure, according to the Centers for Disease Control and Prevention (CDC). Among patients with SSIs who die after surgery, the death is directly related to the SSI in three out of four cases.
Almost all experts agree that SSI prevention starts with following basic hand washing practices and implementing strict aseptic procedures.
“Maintaining the sterile field and wearing sterilized gloves and gowns are other well-established practices for enhancing patient safety in the OR,” says Haynes.
Janice Kelly, MS, RN-BC, president of AORN Syntegrity Inc., a subsidiary of the Association of periOperative Registered Nurses (AORN), lists several other steps for improving patient safety in the OR.
One of these is standardizing surgical scheduling to reduce the number of duplicate procedures in the surgical library.
“A standardized surgical procedure list enhances communication and helps ensure that procedure-specific resources are available in the OR, including staff and equipment, so patient care is not impacted,” says Kelly.
Another is improving data collection and getting what you need from your electronic health records (EHRs).
“The collection and analysis of clinical data is how quality improvements for patient care are implemented and monitored,” says Kelly.
To accomplish this, documentation needs to be evidence-based and standardized from one patient to the next, Kelly adds.
“Data must be relevant, accurate, timely and consistent among staff, departments and health systems in order for quality and patient outcomes to be measured,” she says.
Kelly says there is no one-size-fits-all solution to nursing documentation across hospital departments.
“EHRs can give clinicians on-the-spot information about a patient’s medical history; pre-, intra-, and post-operative needs; test results; and other critical information,” says Kelly.
“The documentation in a hospital’s EHR system improves communication of the patient’s current condition, needs and potential risks,” Kelly adds.
Patient Posturing and Positioning
R. Dan Allen, the president of D.A. Surgical, which designs patient positioning devices, has spent 40 years studying anatomy and physiology related to surgical patient posturing and positioning. He says studies have indicated that up to 60 percent of surgical patients suffer some type of physical injury due to positioning issues.
“Patient positioning is a vital first step in having everything right for the entire surgical procedure,” says Allen. “If the patient is positioned incorrectly, every step of the patient’s care and the procedure can be compromised.”
“Positioning is recognized as being every bit as important to patient outcomes as sterile technique, anesthesia, the surgical procedure itself and proper post-op patient management,” Allen adds.
According to Allen, budgetary constraints keep many hospitals from using the most technologically advanced positioning equipment that has been proven to eliminate patient positioning risks during surgery.
“Due to a lack of funding, obsolete positioning equipment is still being employed in some facilities even though the literature is clear in recommending against devices like shoulder braces and candy cane stirrups, “ says Allen. “These were introduced before the Civil War and their continuing use is a cause of irreparable harm and suffering from stretched nerves and muscles.”
Allen recommends that hospitals perform an audit of all their positioners and replace obsolete positioners with new, modern equipment.
“OR personnel should also keep up to date on new positioning techniques and technologies and perform continuing improvement exercises on a regular basis,” he says.
Patient Safety Goals
The Joint Commission recently published its 2017 National Patient Safety Goals, which focus on problems in health care safety and how to solve them. The goals are divided into seven main categories:
- Identify patients correctly – At least two different patient identification methods should be used.
- Improve staff communication – Important test results should be delivered to the right staff person on time.
- Use medicines safely – All medicines should be labeled before procedures begin, and extra care should be taken with blood thinners.
- Use alarms safely – Ensure that alarms on medical equipment will be heard and responded to on time.
- Prevent infection – Hand cleaning guidelines from the CDC and the WHO should be followed.
- Identify patient safety risks – This includes suicide, in addition to other risks.
- Prevent mistakes in surgery – The surgical team must ensure that the correct surgery is performed on the correct patient, in the correct place.
To download the complete list of the Joint Commission’s 2017 National Patient Safety Goals, visit https://www.jointcommission.org/assets/1/6/2017_NPSG_HAP_ER.pdf.
AORN’s comprehensive surgical checklist is another critical tool to help ensure patient safety. It includes specific steps to be followed at four key surgical phases: pre-procedure check-in, sign-in, time-out, and sign-out. The comprehensive surgical checklist is available at www.aorn.org/AORNSurgicalChecklist.
Safety Is Top Priority
Haynes also stresses the importance of making sure that everyone who is present in the OR is comfortable saying something if they see anything that might compromise patient safety.
“OR personnel, including perioperative nurses, shouldn’t feel intimidated or afraid to speak up,” he says.
“Patient safety should be the number one priority for everyone, with no exceptions.”