AORN Journal
Volume 89, Issue 6 , Pages 969-970, June 2009

Using Safety Tools to Prevent System-Related Errors

Article Outline

 

As exemplified in this year's theme, “Reaching the Peak of Perioperative Practice: Safety, Quality, Collaboration,” ensuring patient safety is one of the most important roles of the perioperative nurse. Perioperative nurses advocate for patients during one of the most vulnerable times in their lives. As nurses, it is our ethical responsibility to ensure optimal patient outcomes and prevent harmful errors from occurring.

Unfortunately, wrong site surgery and other preventable errors still occur too frequently in US operating rooms. In fact, wrong site surgery is the most-reported sentinel event.1

As humans, we will make mistakes. By the nature of our work in the OR, we must commit to memory thousands of pieces of information to be processed and analyzed when caring for our patients, and forgetting one step can mean the difference between life and death. Wachter and Shojania have written,

Most errors are made by good but fallible people working in dysfunctional systems, which means that making care safer depends on buttressing the system to prevent or catch the inevitable lapses of mortals.2(p20–21)

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Improving Systems 

“Systems thinking” can be used to help improve health care processes. According to Wachter and Shojania, systems thinking is

a carefully developed and applied set of rules, standards, checklists, technologies, and training programs that helps good caregivers give good care and prevents them from inadvertently harming their patients.2(p21)

One example of a system-related safety measure is the Joint Commission's Universal Protocol, first developed in 2004 as a mechanism for preventing wrong site, wrong procedure, and wrong person surgery. The Universal Protocol has three elements:

•conducting a pre-procedure verification process that involves verifying the correct person, site, and procedure at various preoperative time points as well as the use of a checklist to ensure that relevant documentation, consent forms, test results, and equipment are available and matched to the patient;

•marking of the surgical site when applicable to remove any ambiguity; and

•performing a standardized time out in the OR involving all members of the surgical team immediately before the procedure begins.3

The “time out” element of the Universal Protocol is a crucial step to prevent wrong site, wrong procedure, wrong person surgery. Requirements of the time out include, but are not limited to, confirming the correct patient, side, site, and position; ensuring accurate consent; determining that relevant images and test results are available and properly labeled and displayed; and discussing safety precautions specific to the patient based on the patient's history and medication use. All the time out participants should agree on the procedure to be performed, and all components of the time out should be documented.3 In support of the Universal Protocol, in 2004, AORN began sponsoring National Time Out Day each June 17,

to raise awareness about the importance of requiring the entire surgical team to pause before all invasive procedures to communicate as a group and confirm key information about the patient and procedures to help prevent errors from occurring.4

More recently, the World Health Organization (WHO) launched a new surgical safety checklist as part of its Safe Surgery Saves Lives Challenge. The checklist is divided into three phases that correspond to the surgical procedure workflow:

•before anesthesia induction (ie, sign in);

•before the first incision (ie, time out); and

•before the patient leaves the OR (ie, sign out).5

The checklist is designed to help ensure the safe delivery of anesthesia, appropriate prophylaxis against infection, effective teamwork among OR staff members, and other essential facets of perioperative care.6 One designated person—often the circulating nurse—is responsible for checking the boxes as the actions are completed in each phase. All items in each phase of the checklist must be completed before the surgical team proceeds to the next phase.5 A pilot study conducted in hospitals in eight cities worldwide demonstrated that use of this checklist during major surgeries lowered the incidence of surgery-related deaths and complications by one third.6

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Navigating the Use of Safety Tools 

Even with added safeguards, preventable sentinel events continue to occur. Although by now, most of our hospitals have implemented checklists and training regarding the Universal Protocol, the real problem contributing to wrong site surgery and other errors occurs when rules, checklists, and standards are not used as intended. Our members have asked AORN to help them navigate the checklists and protocols related to the Universal Protocol, time out, and the WHO surgical checklist. This July 17 to 19 at the annual AORN Leadership Conference in Denver, Colorado, we will hold a panel to address confusion related to these three initiatives and the requirements for each.

If you were to take the number of reported wrong site/procedure/person surgeries and compare that to the actual number of surgeries that occur in this country annually, the prevalence would be relatively small. But these errors are preventable, and one occurrence is one too many, considering the unnecessary pain and suffering that result for our patients and their families. In addition, the emotional impact on the entire surgical team can be devastating and life-changing.

You may believe that you will never be involved with a wrong site, wrong procedure, or wrong patient surgery, and I sincerely hope that is the case for every nurse practicing in the perioperative environment. But let's look at it a different way. If you work in the OR for 20 years, performing 2.5 procedures a day, five days a week, 48 weeks a year, you will have been directly involved in 12,000 surgeries. Are you willing to take a chance by not following the standards, protocols, and checklists?

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References 

  1. Sentinel event statistics as of: March 31, 2009. The Joint Commission . http://www.jointcommission.org/NR/rdonlyres/241CD6F3-6EF0-4E9C-90AD-7FEAE5EDCEA5/0/SE_Stats_3_09.pdf Accessed May 8, 2009.
  2. Wachter RM , Shojania KG . Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes . New York, NY: Rugged Land; 2004;
  3. The Universal Protocol  . Accreditation Program: Hospitals. The Joint Commission . http://www.jointcommission.org/NR/rdonlyres/AEA17A06-BB67-4C4E-B0FC-DD195FE6BF2A/0/UP_HAP_20080616.pdf Accessed May 8, 2009.
  4. AORN, Inc  . National Time Out Day . http://www.aorn.org/NationalTimeOutDay Accessed May 8, 2009.
  5. World Alliance for Patient Safety  . Implementation Manual: Surgical Safety Checklist . 1st ed.. Geneva, Switzerland: World Health Organization; 2008; http://www.who.int/patientsafety/safesurgery/tools_resources/SSSL_Manual_finalJun08.pdf Accessed May 8, 2009.
  6. Checklist helps reduce surgical complications, deaths [news release] . Geneva, Switzerland: World Health Organization; January 14, 2009; http://www.who.int/mediacentre/news/releases/2009/safe_surgery_20090114/en/index.html Accessed May 8, 2009.

 Editor's note: The Universal Protocol is a trademark of the Joint Commission, Oakbrook Terrace, IL.

PII: S0001-2092(09)00343-3

doi:10.1016/j.aorn.2009.05.019

AORN Journal
Volume 89, Issue 6 , Pages 969-970, June 2009

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