Seeking Safety

Most ORs are using some version of the World Health Organization (WHO)'s Surgical Safety Checklist.

When used correctly, the safety checklist provides a foundation that every OR needs: communication, teamwork, a culture of safety and mutual respect, says George Molina, MD, MPH, a surgical oncology fellow at the Dana Farber Cancer Institute, Brigham and Women's Hospital and Massachusetts General Hospital. But the checklist isn't an ironclad, unchangeable document.

"One of the biggest markers of whether a hospital or surgical center is using the WHO surgical safety checklist well is whether they have modified it," says Dr. Molina.

The logistics of getting a patient into the OR will vary from one facility to another — and your checklist should reflect those site-specific challenges, says Dr. Molina. For example, facilities that do a lot of cases where there's an open oxygen source and a heat source in close proximity might incorporate a fire risk assessment score into their safety checklist.

Errors are going to happen in the OR, says Dr. Molina. Just as an anesthesiologist could miss a patient's allergies, a surgeon could just as easily confuse one patient for another or mark the wrong leg for surgery. The checklist gives everyone an equal opportunity to speak up. It's the difference between a mistake that's caught, and a mistake that leads to serious consequences.

"Having these hard pause points leads to better care," he says.

Most safety breakdowns stem from poor communication, says Dr. Wahr. "You should always ask: 'What do I know that other people in the room don't know?'"

An example: Dr. Wahr remembers treating a Jehovah's Witness who needed a hip replacement. As the anesthesia provider, Dr. Wahr learned her patient could not accept a blood transfusion — doing so during medical care goes against the religious group's beliefs — and she alerted the surgeon. That kind of communication makes the difference between a smooth procedure and one that takes an unexpected turn.

"It became a part of our briefing," says Dr. Wahr. "She's a Jehovah's Witness, but with her hemoglobin volume she should be able to lose 2,000 mls of blood, and she'll be fine. Do we anticipate blood loss?"

Surgical facilities need to ask specific safety questions, says Dr. Wahr. How often are your anesthesia providers washing their hands? Is your OR team drifting through the items on the safety checklist or are they really engaged? You should audit these processes just like you audit your infection rates.

"We need to really understand that the checklist means the same thing to us as it does to a pilot," says Dr. Wahr. "If you miss something on that checklist, you may be flying this airplane right into the ground."

Anyone working in an OR needs to have a clear understanding about the safety procedures in place, says Deborah Spratt, MPA, BSN, RN, CNOR, NEA-BC, CHL. A good orientation program sets the tone to ensure your employees are starting on the same page.

"You can't just show someone how to do something," says Ms. Spratt, executive director of perioperative services at University of Rochester St. James Hospital in Hornell, N.Y. "It's so important that they understand the why of what they are being told. It's not just how to count, but why it's important to count. It's not just how to prep, but why it's important to prep the way we do."

From one perspective, it might feel like a burden to identify a patient by his or her name and birthday at every point of contact. Such a policy requires your staff to check again and again that you have the right person for the right procedure.

But when you realize the stakes, it becomes clearer, says Ms. Spratt. "It's not like we're asking because we don't know. We're asking for patient confirmation." The 2-factor verification prevents patients from having a surgery on the wrong site or worse. In 2017, the Joint Commission reported 95 cases where facilities had the wrong patient, operated on the wrong site or performed the wrong procedure.

"Wrong-site surgery," says Ms. Spratt, "somehow is still a terrible problem."

Safety isn't just about policies and procedures; it's about having a realistic expectation for how much surgery you can do in a day. For surgical facilities, it can be a difficult balance of competing interests.

"For patient safety in operating rooms, the biggest challenge is productivity pressure," says Gail M. Horvath, MSN, RN, CNOR, CRCST, senior patient safety analyst and consultant for the ECRI Institute in Plymouth Meeting, Pa.

The pressure to keep up the patient volume can clash with your safety protocols, says Ms. Horvath. An overly ambitious case load could lead to skipped steps on the checklist or unsterile instruments. Your need for speed can't supersede your obligation to safety, she says. When you look at your room turnover, for example, everyone should be working from a common definition and seeking to hit a realistic time, says Ms. Horvath.

"What do we do to relieve these pressures on the people at the front line providing care in the OR?" asks Ms. Horvath.

Human error in counting sponges and instruments can lead to disastrous mistakes. Technology to reduce retained items might have some upfront costs, but you're only one missed sponge away from an even bigger payout and headache.

"It's sometimes getting people to see cost avoidance rather than cost savings," says Ms. Horvath.

Policies can guide your facility toward a safer OR, but it's up to your staff to put them into action.

When David Comer, RN, BSN, CNOR, greets a patient before surgery, he follows the same procedure every time. It doesn't matter if he has a patient's chart in front of him or he received the information from another nurse, he confirms key elements himself. He's asking about implants, pacemakers, NPO and allergies. He's double-checking that the correct patient is having the correct procedure at the correct time.

"I just want to hear it from the patient's mouth," says Mr. Comer, a circulating nurse at McLaren Macomb in Mount Clemens, Mich.

After participating in thousands of procedures over 35 years, Mr. Comer says it might be easy to take the process for granted. Those years of experience can make you feel like you've seen it all.

"I can't become complacent in that," says Mr. Comer. "That's when you start to miss things."

For him, safety in the OR is all about one key principle that has become second nature.

"You have to do it the same way all the time," he says. OSM