When she witnessed a near mix-up between a hernia repair and an orthopedic surgery for a pediatric patient, the lightbulb went off for Krista Bragg, DNP, CRNA, chief nurse anesthetist and manager of perioperative education at The Reading Hospital and Medical Center in West Reading, Pa.
Patient safety in the operating room is still not as good as it should be.
Hospitals stopped receiving reimbursement for wrong patient, wrong site and wrong procedure surgeries in 2009, according to Dr. Bragg, and while wrong surgeries have decreased since then, they are still happening. At current rates, each 600-bed hospital can expect to see at least one wrong site surgery per year.
Since time out processes were put in place in 2004, surgical errors have also not improved as much as clinicians hoped. Errors still occur 4,000 times a year in the U.S., according to Dr. Bragg. Foreign objects are left behind 39 times per week and wrong site surgery occurs at a rate of 20 times per week.
To help improve patient safety in the OR, Dr. Bragg highlighted the following seven points to consider in a May 9 session at the Becker's Hospital Review 6th Annual Meeting in Chicago.
1. Involve physician champions in the time out process. This process is critical to establishing the basics, making sure the OR team is operating on the right patient, for example. However, pressure to get the surgery started causes many teams to rush or providers to skip the time out process. Surgeons, followed by anesthetists, are most likely to miss the time out process, according to Dr. Bragg. "When you have surgeons or providers who are not compliant or who do not like to participate in the safety culture you have a real problem," Dr. Bragg said. This isn't always because providers don't want to participate, but the procedure is often performed at the most inopportune time, she said. The team may perform the time out process while the anesthetist is at work or the surgeon is prepping. The key is to involve physician champions, she said, to encourage and ensure all providers participate.
2. Customize the surgical checklist. "The time out process takes care of the low-hanging fruit," Dr. Bragg said. "The checklist takes care of the next layer." The checklist is essential for patient safety in the OR. For example, at one facility, Dr. Bragg recounted a hip replacement surgery in which the patient was cut open down to the bone when the surgeon realized the equipment wasn't sterile — the C-arm hadn't been draped. The surgeon froze and didn't know how to proceed. The team decided to close the patient up and abort the surgery at that time.
"Nine out of 10 times the surgical checklist doesn't find anything new, but the one time it does can make a big difference," Dr. Bragg said. The checklist should also be customized to fit the particular needs of each institution. Now, the C-arm has been added to the checklist at the facility where the hip replacement went awry.
3. Provider fatigue is serious. Dr. Bragg recounted an instance in the parking lot after a 24-hour CRNA shift at a Level I trauma center. She accidentally put her car in reverse instead of in drive and hit the car behind her. After another 24-hour shift, she accidentally threw away her car keys instead of the soda in her hand. She had to dig through the garbage to find them in front of her son and his friends. The expressions on their faces were enough to make her stop 24-hour shifts, she said. However, for some clinicians and patients the accidents are much more grave. Dr. Bragg recommends shifting from a 24-hour cycle to a 16-hour cycle. Even though the 24-hour cycle is a better fit for the physician schedule, it's not better for the patient.
4. Proctor new providers on robotic-assisted surgery. Robotic procedures are popular in the OR and can be used fairly often. The key to using robots, according to Dr. Bragg, is to proctor new providers on robotic-assisted surgery until they have practiced a certain number of observed surgeries. As with any new technology, a proctor is required before you can assume it is safe, she said.
5. Monitor and address behavior that undermines the culture of safety. Adverse behavior — if a physician screams at staff down the hall while they are taking care of patients, for example — can profoundly affect safety in the OR. Intense anger can impact the ability to think clearly. The Joint Commission sees this as a major safety risk, Dr. Bragg said. If an OR is dealing with a destructive provider or other staff member, human resources should be involved and anger management training may be necessary.
6. Prioritize checking for CRE in duodenoscopes. "We believe this hazard requires immediate action and executive level attention," Dr. Bragg said. She noted a facility that takes microcultures of its duodenoscopes and does not use the scope until it comes back clean. This process may take up to three days, so facilities will need extra scopes, which is expensive. Another strategy is to take both random and regular microcultures of the scopes.
7. Be prepared to take action against epidemics and deadly pathogens. While Ebola preparedness is becoming less urgent, Dr. Bragg stressed that it is still important to know what to do when presented with a possible Ebola patient. She said institutions need to ask themselves, 'If a patient comes in puking and staff ask Ebola screening questions, is there a process in place if the patient answers yes?'
8. Pediatric safety is different than adult safety in the OR. Patients ages 0 to 14 years old are twice as likely to die in a hospital at mixed-age centers than at pediatric centers. Children's Hospital of Pittsburgh once transferred in a 10-year-old patient after six hours of blood transfusion. The child had been given eight units of regular blood, Dr. Bragg said, but not enough platelets. The child came back for years to Children's Hospital with brain damage from the transfusion. Even at a good adult hospital there is no guarantee that practitioners can take care of a child the same, Dr. Bragg said.
Above all, Dr. Bragg said, the most frequently reviewed sentinel events involve foreign objects and wrong patient, wrong site or wrong procedure surgery. "The biggest bulk of errors in the OR have to do with poor systems and the lack of mindfulness," she said. Often, it is assumed that clinicians already provide safe care, but nothing should be taken for granted. Staff at all levels — even hospital leadership — must have an understanding of and involvement with patient safety issues in the OR.