By Don Sadler

When you stop and think about it, recent advancements in surgical technology and medical care are truly astonishing. However, there’s still significant risk every time a surgeon’s scalpel touches a patient’s skin.

It’s up to perioperative personnel and surgical teams to do everything within their power to reduce these risks. “This starts with creating a culture where ensuring patient safety is a core organizational value,” says Patricia McGaffigan, RN, MS, Vice President, Safety Programs, at the Institute for Healthcare Improvement (IHI).

Common Patient Safety Risks

Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, the Director of Evidence-Based Perioperative Practice for the Association of periOperative Registered Nurses (AORN), reels off a long list of safety risks faced by patients undergoing surgery.

“Surgical site infections, wrong site surgery, retained surgical items, medication errors, patient burns and injuries related to positioning remain the most common safety risks in the OR,” says Spruce.

At the core of these risks is often poor communication among members of the surgical team. According to Spruce, 70 percent of adverse events in patient care can be contributed to a breakdown in communication.

“There’s still a fear of punishment among some OR nurses about speaking up if they think something’s wrong,” says McGaffigan. “Perioperative leaders need to identify communication breakdowns like this and be proactive about addressing them.”

Spruce says that improving communication in the OR starts with leaders promoting an environment where all perioperative team members are empowered to speak up when a threat to patient safety is identified.

“Effective teamwork, a systems approach and blameless communication are the best strategies for building a patient safety culture,” she says.

Using Safe Surgery Checklists

One of the best ways to standardize safety measures in the OR is to adopt a safe surgery checklist. Since it was adopted by the World Health Organization in 2008, the Surgical Safety Checklist has represented the global standard of care.

Now used in approximately 50 million operations performed worldwide each year, the Surgical Safety Checklist reduces surgical complications and mortality rates by up to 47 percent. The checklist identifies three critical pause points during surgery:

  • Before the induction of anesthesia.
  • Before the incision in the skin.
  • Before the patient leaves the operating room.

“At each pause point, the checklist encourages preparation, communication and adherence to important practices that reduce errors and help surgical teams work together better,” says Alex Haynes, MD, MPH, Director for the Safe Surgery Program at Ariadne Labs and Associate Professor of Surgery at Harvard Medical School.

“By using the Surgical Safety Checklist to build effective communication and teamwork, surgical teams can minimize the most common and avoidable risks endangering the lives and well-being of their patients,” Haynes adds.

Ariadne Labs and the South Carolina Hospital Association recently concluded a five-year study to gauge the large-scale impact of using safe surgery checklists. The study revealed a 22 percent reduction in post-surgical deaths at hospitals that voluntarily completed implementation of the Surgical Safety Checklist.

Spruce says that surgical safety checklists can serve as “valuable practice standardization tools by providing structure for all perioperative team members to know what’s important in practice situations and be prepared to perform tasks at the right time.”

Spruce believes it’s important that surgical checklists be designed by the perioperative team members that will be using them. “Input from individual team members helps identify care relevant to specific patient populations and decrease variability,” she says.

“When checklists are designed by individual teams, they become more meaningful and relevant and not just something else team members are required to do,” Spruce adds.

AORN has developed a comprehensive surgical checklist that includes specific steps to be followed at four key surgical phases: pre-procedure check-in, sign-in, time-out and sign-out. The AORN comprehensive surgical checklist can be downloaded at www.aorn.org/AORNSurgicalChecklist.

Trends in Patient Safety

A noteworthy recent trend identified by Spruce when it comes to improving patient safety is the adoption of simulation training by more hospitals.

“This provides an avenue where team members can practice patient safety scenarios and discuss team decision-making in a safe environment,” says Spruce. “Simulation training teaches effective teamwork, a systems approach and blameless communication. These are the best strategies for building a culture where patient safety comes first.”

Spruce also recommends using the latest new technologies to mitigate risk in the OR and improve patient safety.

“For example, using RFID technology in addition to manual counts can reduce the risk of retained surgical items,” says Spruce. “OR professionals and leaders should be aware of new technologies and evaluate their use in perioperative practice to help minimize risk to patients.”

McGaffigan points to yet another major patient safety risk in the OR: surgical fires. “The FDA recently made recommendations to all health care professionals involved in surgical procedures to help reduce instances of surgical fires and related patient injuries,” she says.

According to the FDA, surgical fires can occur at any time when all three elements of the “fire triangle” are present: an oxidizer, fuel source and ignition source. Most surgical fires occur in oxygen-enriched environments where the concentration of oxygen exceeds 30 percent.

To reduce the possibility of surgical fires occurring in the OR, the FDA recommends conducting a fire risk assessment before each surgery begins. Health care professionals should also practice the safe use and administration of oxidizers and any surgical suite items that could serve as fuel or ignition sources.

In addition, health care professionals should plan and practice how to manage a surgical fire if one erupts in the OR, says the FDA.

The Risk of Linting

Kevin J. Freidman, the medical director at Halyard Health, points to another common but less-publicized OR patient safety risk: linting.

“Lint and foreign debris from gowns, drapes and other common OR products can contaminate surgical instruments and devices, increasing risk of infection,” says Freidman. “The consequences can be life-threatening.”

To reduce this risk, Freidman says many hospitals are moving toward standardization with regard to surgical apparel.

“We’re also seeing a move away from woven linen fabrics to polypropylene drapes and gowns to reduce linting in the OR,” he adds.

Additional steps recommended by Freidman to limit the risk of linting include:

  • Opt for powder-free gloves
  • Cover linting clothing while walking in and out of critical areas
  • Ban newspapers from the OR because they contain cellulose with dyes and ink
  • Clean, dry and assemble devices in low-linting sterile processing areas
  • Make sure that air filtration units are performing optimally

According to Freidman, some surgical gowns meet AAMI Level 3 and 4 requirements for protection.

National Patient Safety Goals

The 2018 National Patient Safety Goals published by The Joint Commission focus on problems in health care safety and how to solve them. The goals include correct patient identification, improved staff communication, safe use of medicines and alarms, infection prevention, identification of patient safety risks and the prevention of surgical mistakes.

To download the complete list of 2018 National Patient Safety Goals, visit https://www.jointcommission.org/assets/1/6/2018_HAP_NPSG_goals_final.pdf.