The inherent challenge of providing safe surgical care increases in the fast-paced, pressure-cooker world of outpatient surgery, where the thin line between expected outcomes and adverse events can be erased with a split-second lack of focus, communication failure or honest mistake.

To find out what products and technologies facilities are using to support surgical teams in their efforts to first do no harm, we asked readers to share which safety-minded solutions are found in their ORs and reprocessing rooms. Here's what they identified as essential tools in their continuing efforts to protect patients from preventable harm.

• Non-invasive monitoring. Pulse oximetry and capnography monitors are invaluable adjuncts to basic vital signs monitoring, according to Mike Morel, CRNA, APRN, MSNA, PhD(c), co-chief of anesthesia at Volunteer Community Hospital in Martin, Tenn. Capnography measures end-tidal carbon dioxide (ETCO2) — the concentration of CO2 in exhaled breaths — to help providers confirm oxygen exchange is occurring in the lungs and alert them to a possible obstructed airway. Pulse oximetry measures blood oxygen levels to provide a real-time indication of how well patients are oxygenated.

Dr. Morel, a sworn devotee of both monitoring platforms for years, acknowledges the technologies are neither new nor innovative. He also doesn't care. "I'm an ol' dawg," says the 68-year-old Dr. Morel in a drawn out southern twang. "These monitors have saved many a patient."

• Video laryngoscopes. Most airways can be secured with a standard laryngoscope blade, which is simple to use, safe and effective. Many patients undergoing more complex surgery in today's outpatient ORs are sicker, heavier and have numerous comorbidities, factors that make managing the airway more challenging. Enter the video laryngoscope, a user-friendly airway device that provides direct views of the glottis for easier endotracheal tube placement. ?Having such a tool on hand to take most of the difficulty out of managing difficult airways is developing into the standard of care.

Positioning pads. Don't be lulled into a false sense of security when placing patients in basic supine and lateral positions, which demand attention to detail and care in order to prevent pressure injuries from forming and nerve damage from occurring. Randall Rentschler, RN, perioperative director at Artesia (N.M.) General Hospital, says his staff places a gel roll under the axilla of patients placed in the lateral position to reduce pressure on the neural plexus. When patients are supine, he adds, their arms are positioned close to their body to prevent nerve damage at the brachial plexus.

When placing patients in more elaborate positions such as deep Trendelenburg, Mr. Rentschler suggests relieving pressure on the shoulders, which press against support braces attached to the surgical table on either side of the patient's head. You can also prevent the patient from slipping by placing a stabilizing pad between the patient's lower back and the table's surface. "Proper patient positioning is about preventing neuroplexus issues and direct pressure injuries," says Mr. Rentschler. "Circulators should be responsible for facilitating appropriate positioning and ensure pressure points are appropriately padded."

• Endoscope care. Carbapenem-resistant Enterobacteriaceae outbreaks in California and Washington State related to contaminated duodenoscopes spotlighted the importance of flexible endoscope care. Staff in the facilities where the outbreaks occurred followed proper reprocessing protocols, but inherent design flaws made the duodenoscopes nearly impossible to clean and high-level disinfect.

The FDA has approved the first disposable duodenoscope in an effort to eliminate cross-contamination risks, but Mr. Rentschler says the cost of single-use scopes will likely exceed the budgets of many facilities that aren't affiliated with major health networks, at least until market competition drives down the price point.

Conventional flexible endoscopes don't present the same reprocessing difficulties, but remain challenging devices to disinfect between uses. Mr. Rentschler points to adenosine triphosphate (ATP) testing and the use of borescopes as tools that can improve the care of these hard-to-clean instruments. ATP test strips detect the presence of biological matter and bacteria growth in an endoscope's lumens, and are often used to confirm scopes have been properly cleaned and disinfected before being used on another patient.

"It's standard practice for us to check all of our scopes with ATP testing," says Mr. Rentschler. "We use it as an adjunct to high-level disinfection."

Borescopes let you see inside an endoscope's channels to confirm they're free of bioburden, stains and internal damage — imperfections that can jeopardize high-level disinfection of the instrument. Small-diameter borescopes can fit into the internal channels of most scope models, letting you notice the tiniest of imperfections that can jeopardize patient safety.

Hanging endoscopes in a dedicated storage unit and allowing for adequate dry times after high-level disinfection are essential aspects of proper scope care because, simply, "Bacteria grow in wet scopes," says Mr. Rentschler.

Standard endoscope storage cabinets circulate HEPA-filtered air through the internal chamber to help ensure hanging scopes remain dry, but integrated forced-air drying platforms, which connect directly to an endoscope's ports to send filtered air through internal lumens, represent the next step in drying efficacy.

• Medication safety. Barbara Kirkland, BSN, CNOR, team lead at Ascension St. John Hospital in Tulsa, Okla., says pre-printed and color-coded labels enhance medication identification, especially in the perioperative setting where a single provider is often solely responsible for drug preparation and administration.

Pre-filled syringes, which come in properly labeled single doses, help to ensure staff identify and administer the correct medication. Barcoding systems and automated medication dispensing cabinets are effective high-tech, high-end medication safety solutions, but are often limited to use in large surgery centers, hospitals and health systems.

• Retained object detection. Retained objects are a rare occurrence, but the never event continues to occur in ORs across the country, perhaps because many surgical teams still rely on manual counts instead of tapping into technologies designed to ensure no item is left behind in patients.

Scanning barcodes on sponges before they're placed in the patient and again after they're removed helps to ensure staff reach an accurate count at the beginning and end of procedures. Sponges and towels affixed with radiofrequency tags can be detected with a wand that's passed over the patient. The detection technology works, according to Ms. Kirkland.

"We had a recent incident of an incorrect sponge count, which the surgeon involved in the case disputed," she says. "The patient had a positive abdominal wanding and, after further exploration on the abdominal cavity, the missing sponge was found and retrieved before the patient left the OR."

Safety-focused products are important assets, but so is constantly talking about ways to effectively implement the technologies. "Having the right processes in place and ensuring every member of your team is properly trained to adhere to safety-related protocols is crucial," says Tony Willbur, RN, ADN, director of nursing at Wauwatosa (Wis.) Surgery Center.

"We have daily safety huddles to discuss patient safety issues," adds Ms. Kirkland. "It allows for the staff to talk about the situation, and is a learning opportunity for everyone."

Dr. Morel, the battle-tested anesthesia provider from Tennessee, remembers having to rotate a single EKG monitor through his former hospital's three ORs. Times have certainly changed. He recently learned how to place ultrasound-guided nerve blocks, even though he claims to "throw in" interscalene blocks before his younger colleagues can ready the ultrasound probe. He readily admits, however, that ultrasound helps him place safer, more effective blocks, proving ol' dawgs are up to learning new tricks.

There's a lesson to be learned in his willingness to evolve in the twilight of his career. Look at newer options in safety products not as nice-to-have add-ons, but as important tools that help your team provide the quality of care your patients deserve. OSM

The readers who responded give their staff, surgeons and anesthesia providers tools designed to improve medication safety, pressure injury prevention, airway management and endoscope care, although it appears adoption of retained object detection platforms is lagging behind the use of other safety-related products and technologies.

— ?Daniel Cook

• What do you use to ensure the correct medications are given to the correct patients (check all that apply)?
  Pre-printed medication labels 62%
  Barcode scanning 38%
  Prefilled syringes 52%
• Do you use retained object detection technology? Yes 34% No 66%
• Do you use positioning devices designed to limit risk of pressure injuries?
  Yes 90% No 10%
• Do your anesthesia providers use video laryngoscopes?
  Yes 71% No 29%
• What do you use to improve endoscope care (check all that apply)?
  Closed transport containers 59%
  Borescopes to inspect internal channels 12%
  Storage cabinets with integrated drying technology 22%
  Automated internal channel-drying systems 12%
  ATP tests 49%

Source: Outpatient Surgery Magazine reader survey (n=52), January 2020