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Home  Southeast
Surgery Safety Tips Help Save Southeastern Lives
By Cynthia Saver, RN, MS
Monday November 10, 2008
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In June 2008, The World Health Organization launched a global patient safety initiative, Safe Surgery Saves Lives, to help reduce errors and promote safe surgery worldwide. Facilities in Georgia and the Carolinas are taking the advice seriously.

The WHO initiative recommends that a surgical safety checklist be used for each procedure, and that safety checks be done in a three-phase process: sign in (before induction of anesthesia), time out (before skin incision), and sign out (before the patient leaves the operating room).

Preliminary results from eight pilot sites worldwide showed the checklist nearly doubled the likelihood patients would receive proven standards of surgical care, according to the WHO.

Checking and Rechecking

Children's Healthcare of Atlanta recently started using the checklist, according to Kawana Mitchell, RN, CNOR, operating room manager. Five nurses are tweaking the checklist to fit the OR's needs and are working on engaging surgeons in the process. "We're building on the 'time-out' process," says Mitchell.

A checklist facilitates the time-out process, which includes checking for the correct patient, operative site, and position; signed consent; needed radiology images; antibiotics given; and agreement about the procedure to be completed.

"The entire team stops prior to the incision and addresses the time out," says Michele McCammon, RN, BS, operating room manager at DeKalb Medical in Decatur, Ga. That includes the surgeon, RNs, surgical technologist, and anesthetist.

Signs posted inside each OR remind staff to take a time out. The surgical tech does not attach the blade to the knife handle until the time out has been completed.

McCammon says additional safety considerations include checking whether the patient has a latex allergy, respiratory precautions, and any other medical concerns.

At DeKalb Medical, a "hall pass" promotes communication when a patient is transferred. "Every nurse who is transferring care of the patient to another nurse uses the hall pass as an additional tool to ensure continuity of care," says McCammon. Nurses sign their names and telephone extensions so they can be reached quickly if there are questions about the patient.

Nurses at St. Francis Hospital in Charleston, S.C., use an office white board that's posted in each OR where all the team members can see it. The nurse jots down key pieces of information such as the patient's name, date of birth, team members' names, preoperative antibiotics (if the patient received any), and counts of sharps, sponges, and instruments.

Communication outside the OR is important, too. Nurses use a flow sheet for intradepartmental communication. The flow sheet, which is not part of the patient's permanent medical record, starts in the ambulatory or inpatient unit and goes through to the PACU. Preoperative information includes medication reconciliation and specifies whether a history and physical are on the chart. Intraoperative documentation includes what local anesthetic was used and what dressings were applied.

Staff may document the time out on paper or in the computer, as is done at St. Francis, where Pam Smith, RN, CNOR, is clinical nurse manager. Smith says time out isn't just for show — it has real results. For instance, a nurse circulator "brought everything to a halt" when the time out revealed a discrepancy as to the correct operative finger. Once everyone was on the same page, the surgery continued.

Of course, time outs are just one part of surgery safety, says Priscilla Ramseur, RN, MSN, administrative director for Duke North Operating Rooms at Duke University Hospital in Durham, N.C. Other areas include medication safety, aseptic technique, and the count process.

"It's a challenge in the OR to have the six rights [of medication delivery]," says Ramseur. Surgeons, anesthesia care providers, pharmacists, and nurses have worked together to streamline the system. For example, the anesthesia provider soon will enter all medications given in the OR into the computer so a comprehensive list is readily available to the PACU nurse.

It's important to capture near misses, as well as errors, says Ramseur. These can help identify potential problems. "Maybe something is posted incorrectly or the nurse didn't have all the needed information," she says. Ramseur also advises managers to closely examine safety reports for trends.

Safe Talk

Smith frequently discusses safety at her daily morning staff meeting. "We talk about situations where we could have done better, look for opportunities for improvement, and celebrate our successes," she says of the meetings, which include RNs, surgical technicians, patient care assistants, and central supply staff.

To ensure staff get the message that safety is the "No. 1 priority," senior leadership at Duke hold regular "safe choice" conferences that include top management and staff, says Clif Flintom, an administrative director of business and finance who is assigned to perioperative services. Staff are invited to the off-site, all-day conference. "We don't make it mandatory," says Flintom, who says about 150 staff members attend.

At the conferences, staff can talk about making good choices, consider what could be done differently to promote safety, and discuss other safety issues. Staff are encouraged to share what they learned with others so behavior is changed.

At the Medical University of South Carolina in Charleston, time outs end with a simple, but important, step. "Everyone in the room introduces themselves," says W. Zeh Wellington, RN, a staff nurse who specializes in pediatric cardiology. Knowing who is in the room is especially helpful in the case of an emergency, but Wellington points out another key benefit: "It helps everyone to work as a team, and OR safety is all about teamwork," he says. "We're all in this together for the safety of the patient."

Learn more about the initiative at www.who.int/ PatientSafety/SafeSurgery/en/, where you can download tools and training materials.

Cynthia Saver, RN, MS, is president of CLS Development Inc. in Columbia, Md.

To comment, e-mail editorSE@nursingspectrum.com.

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