A Simple Tool Makes Surgery Safer

No surgeon wakes up in the morning with the intention of performing a wrong-site surgery and yet these types of never events continue to happen, even with protocols and practices in place to prevent them. It's clear the inconsistent or improper use of checklists before and after surgery continues to be an issue at surgical facilities across the county.

Checklists are multidisciplinary tools, but not all participants in pre-op time outs are actively engaged in completing them. Because of this, Kimberly Platt, MSN, RN, CAPA, director of nursing surgical services at Cleveland Clinic's Marymount Hospital, helped launch the "Summer of Safety" initiative with the aim of re-educating the perioperative team about the importance of performing time outs and using checklists to improve patient safety —and how to implement each properly.

"Some nurses said they needed a checklist, a visible aid, so we set out to develop a checklist that created actual accountability for each step of the Universal Protocol," says Ms. Platt. "The sign-in, time out and sign-out now have specific communication tasks for each team member to complete in order to ensure all items are addressed."

The hospital's leadership and quality officer developed action steps, which included bi-monthly leadership team meetings, a communication plan to relaunch the facility's safety checklist, a reassessment of the current audit tool to make sure its elements matched the safety checklist, and developing a plan for real-time data collection and analysis. They also determined the number of daily audits they wanted to perform to ensure the surgical team was properly performing safety time outs, and developed auditor training and multifaceted education programs to support the understanding of how the Universal Protocol impacts patient safety and team collaboration.

"We had IT create an iPad audit tool, and the nursing quality assurance program manager provided training to two OR nurses on how to use it as secret auditors," says Ms. Platt. "The nurses record whether surgeons, nurses, anesthesia providers and surgical technicians properly complete their defined roles on the patient safety checklist."

In order to get accurate data, it was extremely important for these nurses to be very honest in their assessments. "We were able to track the compliance of the Universal Protocol for 45 to 60 days, and then we analyzed all the data," says Ms. Platt.

Kristy Simmons, MSN, RN, CNOR, a NICU OR resource nurse and Magnet Nurse Champion Chair at Women's Hospital in Baton Rouge, La., once noticed surgical errors and sentinel events were more likely to happen at the end of a case as the OR staff verifies surgical counts, closes out the patient chart and goes over patient-specific concerns with the surgeon. The most common errors included failing to document accurate procedures when a scheduled diagnostic case turned into an interventional procedure, specimens getting lost and inaccurately documenting the patient's blood loss.

"We reviewed sentinel events and realized that most of the improvements we had to make related to processes in place at the end of the case," says Ms. Simmons. "We needed to educate the staff on the proper ways to close out a chart, conduct a debriefing and verify with the surgeon what exactly they did during surgery." As a result, the facility developed a debriefing card and tailored it to the specific needs of the facility's patients. The main circulating nurse runs through a checklist on the form, which promotes patient safety and communication among the OR staff. "It allows us to verify the actual procedure that was performed, the amount of blood loss, that specimens were properly collected and that every aspect of the procedure is properly documented," says Ms. Simmons.

Before implementation of the debriefing card, eight sentinel events occurred involving inaccurate counts, blood loss, retained objects, missing specimens and inaccurate documentation of the procedure that was performed. Post-implementation, the facility recorded only two sentinel events, a 75% reduction. With the help of the debriefing card, handoffs with the recovery staff also run more smoothly and miscommunication between caregivers happens less frequently.

In this age of uncertainty, it's reassuring to know that a simple safety checklist or debriefing card can prevent something as devastating as a never event. Still, it's not an easy feat to get physicians and staff to alter their routines, especially those who might still view time outs and debriefings as tedious.

"When we first implemented the debriefing card, the main circulator would run through it quickly, but now surgeons step back from the field and recite exactly what they've done during the case without having to be reminded," says Ms. Simmons. "It took some surgeons time to get used to the change, but once they understand that we're trying to do what's best for their patients, they're more than happy to go along with it." OSM