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8/2/2019 Updates on Patient Safety in the Perioperative Setting
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UPDATES ON PATIENT SAFETY IN THE
PERIOPERATIVE SETTING
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PERIOPERATIVE NURSING
What is Perioperative Nursing?
It is an individualized surgical nursing carein order to restore or maintain the health and
the welfare of the surgical patients/ clients
before, during and post surgical interventions.
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Objectives:
1.To help the surgical clients return as rapidly as
possible to the best physical and mental
health attainable.
2.To ease the pains/ discomfort of the surgical
patients and in case the patient did not return
to his health, he/ she should be allowed to die
in peace and with dignity.
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GOALS:
1. To provide a safe , supportive, and
comprehensive care.
2. To assist the surgeon by functioning
effectively as a member of the surgical
team.
3. To create and maintain an aseptic /sterile
environment.
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CORE VALUES OF PERIOPERATIVE NURSING
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FUNCTIONS AND RESPONSIBILITIES OF A SCRUB
NURSE
A. Pre Operative Phase Checks the card file for surgeons special needs/request
Opens sterile supplies/packs and linen
Scrubs, gowns and gloves and sets up the sterile field.
Checks for proper functioning of each instruments Performs initial counting with the circulator
Initiates TIME OUT PHASE
B. Pre-Incisional Phase
Completes the final preparation of sterile field Assists surgeon with gowning / gloving
Assists surgeon with draping and passes off suction/cautery lines
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C. Intraoperative Phase
Maintains orderly sterile field
Anticipates the surgeons needs( supplies/
equipment)
Maintains internal count of sponges, needles and
instruments
Verifies tissue specimen with surgeon, and passesoff to circulator;
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D. Closing / Post Operative Phase
Counts with CN at proper intervals
Organizes closing suture and dressings
Begins clean - up of used instruments and
equipment
Applies sterile dressings
Prepares for terminal cleaning of instruments and
non-disposable supplies Reports to charge nurse/head nurse for next
assignments.
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Acts as the Circulating Nurse
A. Preoperative Phase
Prepares materials needed for the operation
Checks availability and completeness of the
supplies, equipment and instruments necessaryfor the operation
Assists and attends to the needs of the
anesthesiologist.
Assists SN in gowning
Performs and records counts
Admits patient to surgical suite.
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B. Pre-incisional Phase
Transports patients to procedure room
Assists with the positioning of the patient
Assists anesthesiologist during induction
Performs skin prepping Assists in draping the patient,
Connects suction and cautery lines in the machine
Fixes OR lights
Regulate air conditioning
Provides foot stools as need arises.
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D. Post / Closing Phase
Counts with the SN at proper intervals Finalizes records and charges
Begins clean-up of the area/ procedure room
Applies tape on the dressing
Assists anesthesiologist in preparing patient for transfer
to PACU
Takes patient to PACU with the anesthesiologist with
the chart and endorses significant information Disposes/ endorses specimen with correct label to the
surgeon
Reports to charged / head nurse for next assignment.
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FUNCTIONS OF A PACU NURSE
The PACU Nurse should be able to do thefollowing :
a) Attends quality circle, endorsement of
patients, drugs, supplies, machines and
equipment
b) Attends and prioritizes the needs of the post
surgical patients.
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c. Givesdirect nursing care base on the ABCs:
Airway and Breathing:> assesses airways
> administers O2
> suction machines always available at bed side
Circulation:> hook to pulse oximeter
> checks O2 saturation
> monitors V/S, report to anesthesiologist
in charge for any alterations/ abnormalities> checks bleeding, assesses pain levels of the
patient.
> administers prescribed meds.
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d)Endorses post surgical patients toward/ICUs properly
OTHERS:
Assist in the general activities in the OR such as:
> acts as circulating nurse
> participates in making supplies, etc,
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According to WHO
Patient safety is the absence of
preventable harm to a patient during the
process of health care. The discipline of
patient safety is the coordinated efforts toprevent harm, caused by the process of
health care itself, from occurring to patients.
Over the past ten years, patient safety has
been increasingly recognized as an issue ofglobal importance, but much work remains
to be done.
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WHO Vision
Every patient receives safe health
care, every time, everywhere.
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Introduction:
Maintaining patient safety in the operatingroom is a major concern of surgeons,
hospitals, and surgical facilities. Circumventingpreventable complications is essential, andthe pressure to avoid these complicationsduring surgery is especially important.
Traditionally, nursing and anesthesia staff havemanaged patient positioning and most safetyissues in the operating room.
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To assist operating teams in reducing the
number of SENTINEL events, WHO PatientSafety- in consultation with surgeons,anesthesiologist, nurses, patient safetyexperts and patients around the world has
identified objectives for safe surgery. Theaim of this Checklist is :
to reinforce accepted safety practices
to foster better communication
to have a team work between clinicaldisciplines.
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Key aspects of patient safety in the
operating room includes the following:
thoughtful patient positioning
ocular protection proper handling of electrocautery
and airway management
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If performed correctly with attention
to certain anatomic landmarks,
preoperative positioning of the patient
can prevent nerve injury and
postoperative joint or muscle pain.
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Surgical Safety Checklist
A. Components of the Checklist
a. Period before and after Induction
ofAnesthesia (nurse and
anesthesiologist)
b. Period before Surgical
Incision (N-A-S)
c. Period before Patient Leaves
Operating Room (N-A-S)
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Responsibility of postoperativecomplications ultimately lies with the surgeon.
Careful attention to patient safety especially
during elective procedures is paramount.
Attention to detail in patient positioning, eye
protection, and bovie use can help avoid
unnecessary perioperative complications and
significantly improve the patient's cosmeticsurgery experience.
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UNIVERSAL PROTOCOL
The fact that wrong- site , wrong- procedure and wrong- person
surgeriescontinue to happen is disturbing, however, thegood news is that they can be prevented.
a. Preoperative Verification Process
Purpose of this process
to ensure that all relevant documents and studies areavailable prior to thestart of the procedure,
that they are reviewed
they are consistent with each other, the patients
expectations, andthe teams understanding of the intended patient,
procedure, site and any implants ( as applicable). Any missinginformation or discrepancies must be addressed during thistime.
.
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b. Marking of the surgical site
Purpose of this process:
to identify the laterality of the surgical siteusing permanent pen.
c. A time-out that is held immediately before thestart of a procedure.
Purpose of this process: -
to conduct a final verification of the correctpatient, procedure, site, patient position andas applicable , availability of implants andspecial equipment/instruments
this requires active communication betweenteam members.
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How to run the Checklist (in brief)
To implement the checklist during the surgery,
a person must be made responsible .The
checklist coordinator/ circulating nurse will do
or perform the checklist.
All steps should be checked verbally with the
appropriate team member to ensure that the
key actions have been performed
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Before induction of anesthesia
- the CC/CN will verbally review with the
anesthesiologist and patient( when
possible ) that patient identity has been
confirmed, that the procedure, site are
correct and that consent for surgery has
been given.
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Before Skin Incision
-each team member will introduce him/herself by name and role. The team cansimply confirm that everyone in the room
is known to each other. The team willconfirm out loud that they areperforming the corrcet patient,
procedure, laterality, prophylacticantibiotic has been given 60 minutesprior to the operation.
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Before leaving the Operating Room
- The team will review the operation that
was performed, completion of sponge,
instruments and labeling of any surgical
specimens obtained.
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In summary:
Having a single person lead the CHECKLIST
process is essential for its success. In the
complex setting of the OR, any of the steps
may be overlooked during the fastpacedpreoperative, intaroperative and post
operative preparations
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Designating a single person to
confirm completion of each step of
the Checklist can ensure that thesafety steps are not omitted in the
rush to move forward with the next
phase of the operation.
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IMPROVING COMMUNICATION AND
AVOIDING DISTRACTIONS
Creating a Culture of Communication
Effective communication is:
a. complete
b. accurate
c. timely
d. unambiguous/precise
e. clearly understood
Some ways to establish and support a culture ofcommunication:
a. provide the staff access to leadership
b. eliminate hierarchies between the staff
c. encourage a team approach
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Provide the staff access to leadership
should have access to organization leadership to provide generalfeedback(reporting)
shouldexpress concerns andfrustrations and celebrate success
Eliminating Hierarchy
Team leaders must work to eliminate hierarchies within the area, the
Team Leaders must sets tone for team interactions. He/she works to
flatten hierarchies by using first names, engage in the care process and
incorporate suggestions and expertise of individual team members into
the plans.
Need to overcome the educational experiences of the staff
Need to be trained to think as individuals rather than as a team
Consider teaching communication skills to all health care providers
Provide team training
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Encourage a Team Approach to Care
Effective teams are characterized by :trust, respect,and Collaboration
Team members value familiarity over formality andwatch out for each other to avoid mistakes. Such
actions are the following:
a.Encourage Feedback provide staff with regular andconstructive feedback and information
b. Provide team training training can mold a group intoa unified entity that can face problems, identify issues andwork together to care for a patient
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c.Address disruptive behavior - disruptivebehavior is anything that upsets the smoothflow of a situation and can compromise patientsafety decrease staff satisfaction and set tonethat is
contrary to effective communication.
d.Structured communication toolsproperinformation is conveyed
at the correct time to the correct
people. > OR briefing
> Debriefing
> Situational Awareness
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PREVENTING WRONG SITE, WRONGPROCEDURE
, WRONGPERSON SURGERY
RISK FACTORS:
a. Inadequate patient assessment
b. Inadequate medical record review
c. Exclusion of certain surgical team members inthe verification process
d. A culture that does not support open
communication between surgical team members
and fosters the idea that the surgeon is alwaysright and cannot be questioned.
e. Problems related to illegible handwriting
f. Use of abbreviations related to the surgical
procedure, site or laterality
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PREVENTING MEDICATION ERRORS It is important to recognize that medication management in
the OR is very different from that in a typical inpatientclinical unit.
In the OR, medications and solutions must be deliveredaseptically to the sterile field and product packaging may beprevent delivering a medication aseptically in its original
container. Inconsistent and illegible labels or a lack of any labels can
contribute to medication errors.
Safe Medication Practices in the OR
a. Right patient
b. Right medication
c. Right dose
d. Right time
e. Right route
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NATIONAL PATIENT SAFETY GOAL
The Joint Commissions Medication Management standards andNational Patient Safety Goals require organizations to implement
safe medication practices.
Deliver Medications Safely
Label all medications, medication containers( syringes, medicine
cups/glass/basins) or other solutions on and off the sterile field.
Medications are dispensed safely
Verify Medication Labels( all medications in the OR should be
labeled at all times. Any medications lacking an identification labels
should be discarded
Identify patient and confirm medication allergies. ( before a
medication is administered, the perioperative staff should verify
the patients identity.
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STRATEGIES TO REDUCE THE RISK OF MEDICATIONERRORS
a. Establishing Forcing Functions> dose - limit protocol that sets limits on doses of
particular
medications, if a dose exceeded the limit, it wouldbe questioned.
Special permission would be required to exceed adose.
> Automatic Stop Orders/ removing certainmedications
b. Educating the Staff on Safe Medication Practices
c. Creating a Reporting System
Reporting Systemshould not be designed to blamepeople butto identify system vulnerabilities that can leadto lapses in patient safety .
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AVOID POTENTIALLY DANGEROUS ABBREVIATIONS
JOINT COMMISSION DO-NOT USE LIST
Do Not Use 0 Potential Problem Use Instead
U (unit) Mistaken for 0zero, thenumber 4 (four) or cc
Write unit
IU (International Unit) Mistaken for IV(intravenous) or the
number 10 (ten)
Write International Unit
Q.D, Q D,q.d,qd (daily)
Q.O.D.,QOD,q.o.d,qod(every other day
Mistaken for each other
Period after the Q
mistaken for I and the
O mistaken for I
Write daily
Write every other day
Trailing Zero (X.Omg)
Lack of leading zero(.Xmg)
Decimal point is missed Write X mg
Write 0.X mg
MS
MSO4 and MgSO4
Can mean morphinesulfate or magnesium
sulfate
Confused for one another
Write morphine sulfate
Write magnesium
sulfate
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ENSURING FIRE SAFETY
Statistics show that the most common ignition sources ofsurgical fires are :
electro surgery and
lasers, and the most common locations of surgical fires are
in the airway and on the head/face.
THE FIRE TRIANGLE
Although surgical fires do not happen often, they canhave severe consequences, including injury to patients and
staff as well as significant damage to surgical equipment.a. fuel
b. oxygen
c. ignition
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Components of the Fire Triangle
FUEL SOURCE: - alcohol base prepping agents- linens
- dressings
- ointments
- surgical equipment and supplies
- topical anesthesia sprays
- povidone iodine solutions
- synthetic sutures
- human tissue
- gastrointestinal or bladders gases- tracheal tubes/ breathing circuits
- body hair
- blood pressure cuffs
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IGNITION SOURCE: - cautery machines- fiber-optic light sources
- lasers- defibrillators
- halogen lights
- drills
- heated probes
OXYGEN SOURCES - medical grade oxygen
- nitrous oxide
- compressed air
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NATIONAL PATIENT SAFETY GOAL
Reduce the risk of surgical fires
REQUIREMENT : Educate staff including operating licensedindependent practitioners and anesthesia providers on howto control heat sources and manage fuels .
PREVENTION STRATEGIES:
a. Preparing Patients Appropriately
> coat all exposed facial hair located near the surgical site
ina water soluble jelly to make them nonflammable
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>for some facial surgeries, cover the patients eyeswith swabs soaked in sodium chloride.
>be aware that alcoholbased skin preps areflammable and avoid poling or wicking theseflammable liquid preps.
>let the prepped area dry completely before coveringthe site with nonflammable drape.
> caution patients against wearing perfume, cologne,
or hairspray on the day of surgery, as thesetypically contain flammable components andrepresents potential fire hazard.
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b. Using Equipment Safely
ex: ESU : -should be in a standby mode
-should be activated only when the active
electrode tip is in view
- active electrode tip should be kept clean to
minimize the likelihood of sparking or burning of
tissue debris.
c. Maintaining Equipment
Faulty equipment can wreak havoc during surgery. All equipment that is used in the OR should be calibrated and
inspected frequently.
The organization should have a maintenance plan for allequipment and document regular and preventive maintenance toensure that the equipment is safe to operate.
TIP: When choosing new equipment ,organizations should considerits fire safety record and weigh any cost savings against potentialsafety issues.
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d. Controlling Excess Oxygen
Surgical setting have higher- than averageconcentration of oxygen. Nearly 75% of flash fires
are related to oxygen rich atmosphere.
TIP:
use pulse oximeter to monitor a patient
use O2 only when necessary
check O2 connections to make sure they are
leak free
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e. Engage Staff in the FirePrevention
Process
Each member of the surgical team
should play a role in preventing surgicalfires. Staff should be aware of their
roles.
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Responsibilities of the Surgical Team during a Fire
Emergency
WITH IN THE OR
A. Primary Surgeon
- primary surgeon: quickly remove any burning material
from the
patient
- work to extinguish the fire
- control any bleeding- complete the surgical procedure as quickly as possible
- prepare to help evacuate the patient, if necessary
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B. Anesthesiologist
- stop the flow of anesthetic gases if the fire islocated on
the patient/drape
- shut off O2 that is flowing directly to thepatient
- ventilate the room with air
- assist with obtaining portable oxygen, suctionmachine
and other equipment, if necessary.
- determine with the authority havingjurisdiction whether the emergency gas shut offvalues should be turned off.
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C. Scrub Nurse and Circulating Nurse
- remain with, protect, and reassure the patient- identify a fire free escape route
- help remove burning material from the patient
and place it on the floor to extinguish
- help extinguish the fire, if the fire is small.
- disconnect any electrical equipment that canbe disconnected easily and safely.
- save fire material for later investigation.
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D. Orderlies
- ensure that hallways, evacuation routes and exits areunobstructed
- help obtain addition supplies as necessary.
OUTSIDE THE OR
a. Charge nurse or Clinical Leader designated to handle OR fire
response.
determine the number of people in the area. instruct all visitors to exit the area in an orderly fashion
note the time the fire began
communicate with the fire chief or safety officer regarding thefire location
communicate with other OR staff as to the status of the fire andplan of action
work with the anesthesiologist with regards to triage prioritiesfor evacuation
determine whether to evacuate
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b. Administrative Staff
follow organization procedure for reporting a
fire to the authorities
keep telephone lines open
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Steps towards QA program
5 S is a personal disciplinary development thatpromotes attitudinal change and habits. This growsfrom an individual level to an organizational level.
a. Sort ( seiri)
b. Set in order ( seiton) simplifyc. Shine ( seiso)
d. Standardize ( seiketsu)
e. Sustain ( shitsuke)
5 s simplifies our work environment, reduces wasteand no value activity while improving quality efficiencyand safety.
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5 s in the workplace
How to make 5s work in the workplace:
continual practice is most important
setting the momentum
understand the philosophy
look at the deficiency of the current situation
build the courage and mindset that change for thebetter rather than the worse
making it a habit that 5s should become part of
individuals life to make it successful practice
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Chinese Proverb:
Sharpen the tools inorder to do work
effectively
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THANK YOU